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Advanced Practice and the Orthopaedic
Nurse: An Interpretive Study
Anita Taylor
A thesis submitted to the Department of Clinical Nursing, The University of Adelaide in fulfilment of the requirements for the award of Master of Nursing
October 1999
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Table of Contents
Page
Table of Contents ................................................................................................................ ii
Abstract .............................................................................................................................. vi
Statement........................................................................................................................... vii
Acknowledgments............................................................................................................ viii
PROLOGUE ..................................................................................................................... IX
CHAPTER 1: INTRODUCTION ....................................................................................... 1
Implications for the Nursing Profession ............................................................................. 3
Some Early Thoughts .......................................................................................................... 4
Summary of the Thesis ....................................................................................................... 5
Introduction ..................................................................................................................... 5
The Study Context ........................................................................................................... 6
Methodology .................................................................................................................... 6
Method ............................................................................................................................. 7
The Narrative Text ........................................................................................................... 7
An Interpretation .............................................................................................................. 7
Denouement ..................................................................................................................... 8
CHAPTER 2: THE STUDY CONTEXT ........................................................................... 9
Introduction ......................................................................................................................... 9
Competency Assessment .................................................................................................. 10
Expert Practice .................................................................................................................. 11
Advanced Practice ............................................................................................................ 13
Specialty Practice .............................................................................................................. 15
Orthopaedic Nursing Practice ........................................................................................... 19
International Experience ................................................................................................... 23
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Summary ........................................................................................................................... 26
Conclusion ........................................................................................................................ 27
CHAPTER 3: METHODOLOGY .................................................................................... 28
Introduction ....................................................................................................................... 28
Defining Phenomenology ................................................................................................. 30
Interpretive Phenomenology ............................................................................................. 30
Historical Origins .............................................................................................................. 31
Defining Hermeneutics ..................................................................................................... 33
‘Foundational Features’ .................................................................................................... 34
Phenomena – the ‘things themselves’ ............................................................................ 34
'Lifeworld’ – the world of lived experience ................................................................... 34
Reality ............................................................................................................................ 35
Subjectivity .................................................................................................................... 36
Phenomenology: A Critique ............................................................................................. 37
‘Credibility’ ................................................................................................................... 37
‘Rigour’ ......................................................................................................................... 38
‘Universality’ ................................................................................................................. 39
Methodological Application ............................................................................................. 40
Nursing and Phenomenology ............................................................................................ 41
CHAPTER 4: METHOD .................................................................................................. 43
Introduction ....................................................................................................................... 43
Van Manen’s Method ....................................................................................................... 44
1. Turning to the phenomenon of Lived Experience ..................................................... 44
2. Investigating Experience as We Live It ..................................................................... 45
3. Hermeneutical Phenomenological Reflection ........................................................... 46
4. Hermeneutic Phenomenological Writing .................................................................. 47
5. Maintaining a Strong and Oriented Relation to the Phenomenon ............................. 47
6. Considering Parts and Whole: the Hermeneutic Circle ............................................. 48
Study Context.................................................................................................................... 50
The Participants ................................................................................................................ 51
The Researcher.................................................................................................................. 52
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Orthopaedic Nursing ......................................................................................................... 52
Ethics................................................................................................................................. 53
Descriptions ...................................................................................................................... 54
Journal ............................................................................................................................... 56
Interpretive Analysis ......................................................................................................... 56
Hermeneutic Circle ........................................................................................................... 58
Dialogue with the Text...................................................................................................... 58
Writing .............................................................................................................................. 59
Conclusion ........................................................................................................................ 59
CHAPTER 5: THE NARRATIVE TEXT ........................................................................ 60
Introduction ....................................................................................................................... 60
Di....................................................................................................................................... 61
Gina ................................................................................................................................... 65
Ellen .................................................................................................................................. 69
Ben .................................................................................................................................... 71
Anne .................................................................................................................................. 75
Carol .................................................................................................................................. 77
Fay..................................................................................................................................... 80
Emergence of Preliminary Concepts ................................................................................ 84
Conclusion ........................................................................................................................ 89
CHAPTER 6: AN INTERPRETATION .......................................................................... 90
Introduction ....................................................................................................................... 90
Having knowledge ............................................................................................................ 91
Being in the role and outside the role ............................................................................... 97
Being an advocate ........................................................................................................... 101
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Being in control............................................................................................................... 105
Decision making .......................................................................................................... 111
Anticipation ................................................................................................................. 112
Summary ......................................................................................................................... 113
CHAPTER 7: DENOUEMENT ..................................................................................... 116
Introduction ..................................................................................................................... 116
Original Thoughts ........................................................................................................... 117
Significance and Implications for Practice ..................................................................... 118
Potential Ramifications ................................................................................................... 123
Evaluation of the Research Process ................................................................................ 124
Coherence .................................................................................................................... 124
Comprehensiveness ..................................................................................................... 125
Penetration ................................................................................................................... 125
Thoroughness............................................................................................................... 125
Appropriateness ........................................................................................................... 126
Contextuality ............................................................................................................... 126
Agreement ................................................................................................................... 126
Suggestiveness ............................................................................................................. 127
Potential ....................................................................................................................... 127
A Final Comment ............................................................................................................ 128
Reference List ................................................................................................................. 129
Appendix 1: Information Sheet to Participants ............................................................... 135
Appendix 2: Consent Form ............................................................................................. 136
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Abstract
Advanced nursing practice is a broad topic that is often misunderstood. Related terms are
used interchangeably, which tends to engender a degree of confusion over what
constitutes advanced practice. The relationship of advanced practice to expert and
specialty practice is unclear. Health care is increasingly becoming more complex. There
are greater expectations placed upon the nurse practising in this context. Therefore the
role of the nurse must reflect the increasing complexity that exists within a contemporary
health system. Advanced practice provides an opportunity to debate and acknowledge
how nursing practice must reflect modern trends. This study will assist in conceptualising
advanced practice in terms of the nature and scope of advanced orthopaedic nurse
practice.
This study aimed to uncover the meaning of the lived experiences of advanced
orthopaedic nurse practitioners, thereby engaging orthopaedic nurses within the debate.
The methodology employed in this study was Hermeneutic Phenomenology, informed by
Heidegger and van Manen. Seven expert orthopaedic nurse practitioners were asked to
describe an experience in which they believed they performed at an advanced level.
Concepts and themes emerged from the narratives. Themes included: having knowledge,
being in and outside the role, being an advocate and being in control.
Controversy and confusion dominates the debate over what constitutes advanced practice,
both here and overseas. This study highlighted that advance practice is part of a
continuum that describes specialist, expert and advanced practice. It is also an important
concept in contemporary nursing practice. However ongoing clarification and consistency
in terminology would assist immeasurably in identifying standards of advanced practice.
Once this is achieved, the impact of advanced practice on patient care can be ascertained.
vii
Statement
This work contains no material which has been accepted for the award of any other
degree or diploma in any university or other tertiary institution and, to the best of my
knowledge and belief, contains no material previously published or written by another
person, except where due reference has been made in the text.
I give consent to this copy of my thesis, when deposited in the University Library, being
available for loan and photocopying.
……………………………..
Anita Taylor
viii
Acknowledgments
I wish to acknowledge the contribution of the following people.
Firstly I should like to recognise and thank Tina Jones for her support and supervision
throughout. Her approachability, generosity of comment, professionalism and
commitment were very much appreciated.
To my fellow students, especially Rose, and staff associated with the Department of
Clinical Nursing, my thanks for your encouragement.
To the seven orthopaedic nurses, a special thanks. I hope this makes a difference. Your
stories made a difference to me.
To friends and colleagues who have inquired, listened, encouraged and assisted,
thankyou.
Finally and most importantly my family…
To my darling boys Oliver and Elliot, who didn’t always understand why mummy was
studying, why she wasn’t there or why she was so grumpy, my devotion.
To my husband Neil, who gave up his beloved golf, willingly whisked the boys off to the
beach, endured the late nights and provided unerring encouragement and support, my
love.
Prologue
A certain symmetry exists on one level of this thesis. The orthopaedic tree symbolises the
study context. The tree of life symbolises the experiences of the participants contained in
their descriptions. The tree of knowledge represents my journey and the quote from
Murray Bail’s Eucalyptus, which opens chapter three, alludes to the study’s
methodology.
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1
Chapter 1
Introduction
What began as a notion, became a personal journey … This thesis represents my journey.
Like Homer’s character, Odysseus in search of the meaning of life, I sought an
explanation of the world of the advanced orthopaedic nurse. I wanted to know what
advanced practice meant to expert orthopaedic nurse practitioners, because it was my
world too. I had a sense of this phenomenon called advanced practice. Did others share
my view?
Not content with a mere description, I sought the ‘meaning’ of advanced practice.
Hermeneutics offered a means to explicate the phenomenon; to give it meaning by
interpretation. My journey began with a personal reflection on an incident in which I
drew on what I considered advanced practice skills. This exercise served several
purposes, one of which was to reveal my orientation towards the phenomenon in
question, or my ‘pre-understandings’ (van Manen, 1990:46). Secondly I wanted to
recreate the conditions under which the participants would be interviewed; to know how
it might feel, after all I was a participant in the dialogue. It oriented me towards
developing a rapport with the participants and therefore by extension, the text to follow
which was to become the focus of the research purpose.
2
My self-interview also established a baseline as it were. My appreciation of advanced
practice changed throughout the study period as my understanding became more
informed. It was therefore important to capture my initial thoughts.
This thesis has attempted to embrace the complexity of the hermeneutic
phenomenological endeavour. That is to represent the many levels on which the
methodology is applied. At a personal level, as researcher, this work has meaning. At a
participant level there is the narrative which after analysis, transformed the participant’s
experience into a new meaning. I sought interpretive agreement from the participants,
which was confirmed when the participants verified their transcript. At its broadest level
this project represents a contribution to the debate on advanced practice at large, both in a
professional and theoretical sense. Such complexity identifies with the methodological,
philosophical imperative of ‘parts and whole’ of hermeneutic phenomenological inquiry
(van Manen, 1990:33-4).
The purpose of this investigation is to describe and understand the nature of advanced
orthopaedic nurse practice. The research question therefore asks ‘What is the meaning of
advanced practice for the expert orthopaedic nurse practitioner’? The area of interest for
this study becomes the advanced practice of the expert orthopaedic nurse.
The research question required the investigator to pool together a rich description of what
advanced practice actually means to the expert orthopaedic nurse. In order to achieve this
one must return to the source, as it were. That is, obtain a description from the expert
3
orthopaedic nurse of the subtleties of their (advanced) practice. The research question is
premised on the belief that theory is embedded in practice (Benner, 1984), therefore one
is able to extract from description, a definition of advanced practice. The research
question aims to apply the theory of advanced practice to the evidence demonstrated in
practice, as revealed by the data collected.
It is hoped the information gained from the study will contribute to the debate on
advanced practice. This study aimed to engage orthopaedic nurses in the debate, and in so
doing, put an orthopaedic perspective on advanced practice. Furthermore the study aimed
to make a difference to the nursing profession by seeking to understand advanced
practice in the context of orthopaedic nursing.
Implications for the Nursing Profession
This study will provide an interpretation of the advanced practice of the expert
orthopaedic nurse practitioner, ensuring that these nurses are represented in the debate. It
will contribute to the collective knowledge of the nursing profession as this emerging,
contemporary professional issue takes its place in the consciousness of ‘ordinary’ nurses
(Taylor, 1994). Further this study could serve as a basis for assessing the effect, advanced
practice has on patient care and health outcomes in general; an area where more research
is required.
4
Some Early Thoughts
My journey began with an ‘abiding interest’ in advanced practice that evolved from an
interest in the debate on advanced practice that was taking place within the nursing
profession. I had a passion for orthopaedic nursing. I wanted to know how the concept of
advanced practice translated to orthopaedic nursing. What was the status of the generic
advance practice competencies in orthopaedic nursing practice? How were orthopaedic
nurses engaged in this debate on advanced practice? This was my starting point.
The use of personal experiences as a starting point in researching lived experience is
recommended by van Manen (1990:54-8):
…the extent that my experiences could be our experiences that the
phenomenologist wants to be reflectively aware of certain experiential
meanings. To be aware of the structure of one’s own experience of a
phenomenon may provide the researcher with clues for orienting
oneself to the phenomenon and thus to all other stages of
phenomenological research. (van Manen, 1990:57)
My own experiences as an ‘advanced orthopaedic practitioner’ were therefore worthy of
investigation. My underlying assumptions about advanced practice, or pre-understandings
(van Manen, 1990:46) were revealed in a taped, self-interview. The qualities I
emphasised in my self-interview had little to do with specialist knowledge. I recalled an
awareness of the entire (ward) situation and a desire to manage and know this situation. I
described ‘juggling’ the patient care needs at the same time as dealing with an episode of
inter-professional conflict. I had a strong sense of my role, my professionalism and my
patients (fldnte:35). This introductory chapter has so far described my context, at the
5
outset of the research process. The remainder of this chapter will summarise the thesis
framework.
Summary of the Thesis
This is a hermeneutic phenomenological study of the experiences of seven expert
orthopaedic nurses who each described an incident of advanced nursing practice. Their
personal descriptions, whilst unique, shared commonalities and differences with each
other. A dialogue with the narrative texts via the hermeneutic circle, revealed emerging
concepts that culminated in the development of themes. The themes represented the
meaning of advanced practice for these orthopaedic nurses.
Introduction
The introductory chapter will firstly expand upon how the research process began by
describing the researcher’s context. This contributed to the formulation of the research
question - ‘what is the meaning of advanced practice for the expert orthopaedic nurse?’
The research question emanates from an abiding interest the researcher has in advanced
practice and orthopaedic nursing. Experiential meaning was pivotal to this inquiry and
therefore understanding will be generated through the use of hermeneutic
phenomenology.
6
The Study Context
Chapter two situates the study by describing the context in which advanced practice takes
place. The term ‘advanced practice’ is misunderstood largely because of the inappropriate
use of it and other related terms. This chapter describes related terms, such as ‘expert’
and ‘specialist’ practice, and situates the debate on advanced practice in a national and
international context.
Methodology
This chapter explores the philosophical foundation of hermeneutic phenomenology, a
methodology situated in the interpretive paradigm. This chapter advances Benner’s
(1984) premise that theory is embedded in nursing practice by interpreting the everyday
lived experience of seven expert orthopaedic nurses.
Phenomenological inquiry will be informed by Heidegger (1962) in which the
interpretation of lived experience is context related. In order to explicate interpretive
phenomenology, it is necessary to discuss the preceeding school of thought within the
phenomenological movement, that belonging to Husserl. Oiler’s (1982) four foundational
features of interpretive phenomenology will be elucidated. Hermeneutical interpretation
will follow the method described by van Manen (1990). The application of these
methodological principles will be discussed in the context of nursing practice.
7
Method
Chapter four will describe the methodical process undertaken in this study. This study is
informed by the method designed by van Manen (1990). The discussion will elaborate
upon the study context in terms of orthopaedic nurse practice, the participants, and how
their descriptions of advanced practice were captured. This chapter will incorporate
within the discussion an explanation of the role of language, the process of interpretive
analysis and how a dialogue with the text was established via the hermeneutic circle.
The Narrative Text
The process of hermeneutic interpretation began with an introduction and summary of the
‘personal life stories’ or incidents, of the participants: Di, Gina, Ellen, Ben, Anne, Carol
and Fay. Through immersion in the participant’s narratives, preliminary concepts
emerged in the form of impressive words and phrases. A description of these preliminary
concepts followed as a beginning to interpretation.
An Interpretation
The interpretation comprised of themes that exemplified commonalities and differences
from amongst the participant’s descriptions. The themes were: having knowledge, being
in the role and outside the role, being an advocate and being in control.
8
Denouement
Denouement was chosen as the title for this chapter as opposed to conclusion that infers
reaching an end point (Jones, 1996:80), which is anathema to interpretive research.
Whilst the themes were dealt with as discrete entities in this chapter, the reality is they
are inter-dependent. The significance and implications of this study will be discussed
along with possibilities for the future. An evaluation of the research process, informed by
Madison (1990:29-30) is presented. By way of closure, I will review my original
thoughts on advanced practice.
9
Chapter 2
The Study Context
The “Orthopaedic Tree” originated from the eighteenth century book
Orthopaedia: Or the Art of Correcting and Preventing Deformities in
Children by Professor Nicolas Andry, in which it has become the
international symbol of orthopaedic surgery. It illustrates the concept
that a crooked young tree - like a deformed child - can be helped to
grow straight by the application of appropriate forces.
(Salter, 1999:2)
Introduction
This chapter will begin to situate the study. The literature demonstrates that advanced
practice is a broad topic that is often misunderstood. Related terms are used
interchangeably, which tends to engender a degree of confusion in regards to what
constitutes advanced nursing practice. International progress on the issue is well ahead
that of Australia. However, Australia must consider its own context, and critique the
overseas experience in order to progress the national and international debate. This
chapter will describe international developments on the issue of advanced practice whilst
considering the implications for Australian nursing practice.
The relationship of advanced practice to expert and specialty practice is misunderstood.
This chapter will attempt to clarify the association. There are only a small number of
specialty nurse interest groups, nationally, which have contemplated the notion of
advanced practice, let alone integrated the concept into practice. Orthopaedic nurses are
10
yet to embrace this idea into practice.
Competency Assessment
The movement towards advanced practice began with the concept of competency
assessment. The development of the Australian Nursing Council Incorporated (ANCI)
entry to practice competencies for nurses evolved out of a competency based movement
dominant in Australian industry at the time. The beginning practitioner competencies
built upon the concepts of novice to expert competence, embodied in the work of Benner
(1984), but representative of the literature on competency-based education and
competency evaluation emerging from America in the 1980’s.
The definition of ‘competence’ remains confused, contradictory and elusive (Girot,
1993:83; Chambers, 1998:207). Confusion reigns because of the problems associated
with assessment of clinical practice. In nursing practice the ‘tool’ used for clinical
assessment must ideally assess practitioners in the ‘real world’ of practice and in all
aspects of nursing knowledge (Girot, 1993:89). Criticism of competency assessment
surrounds the risk of reductionist measurement of nursing practice, subjective
assessment, and a focus on the performance of tasks (Girot, 1993:88). Both Girot (1993)
and Chambers (1998) suggest reflective practice may overcome the problems of
assessment of clinical nursing practice, although its application requires caution (Heath,
1998:291-3). Critical reflection of practice is one way of assessing intuitive knowledge
and analytical reasoning that characterises expert or advanced practice (Girot, 1993:87).
11
Expert Practice
The notion of expert practice was first explored through phenomenological research in
Benner's seminal text From Novice to Expert (1984), in which Benner established five
levels of competence: novice, advanced beginner, competent, proficient and expert and
seven domains of nursing. Benner examined, phenomenologically, the critical incident
accounts of 130 critical care nurses to reveal knowledge embedded in nursing practice.
Storytelling preserved ‘the language of the familiar, everyday, narrative discourse about
their everyday practice’ (Benner, Tanner & Chelsa, 1992:15-6). Benner believed ‘clinical
exemplars’, or stories that describe nursing practice, would capture the true nature of
nursing (Harvey & Tveit, 1994:45). Furthermore, particularly powerful experiences of
nursing practice, were accorded the status of ‘paradigm cases’ and enabled a better
understanding of what was being described (Benner, 1984:8-9). The use of exemplars
was augmented through the use of interview and direct observation. Adams et al
(1997:221) claims ‘Benner’s account of the expert practitioner has been the starting point
for research and discussion on expertise in practice’; the ‘industry benchmark’ or ‘gold
standard’ if you will, the influence of which is found in the pages of this study.
The definition of expert practice, as purported by Benner (1984:32), incorporated a ‘deep
understanding’ (sourced in a breadth of background experience) and an ‘intuitive grasp’
on the totality of any given situation and has served as one of the most ‘influential
perspectives’ on expert practice (Sutton & Smith, 1995:1038). However the debate on
expert practice has evolved further. A review of expert practice within the literature
revealed that the characteristics of expert practice may also include intuition, superior
12
skills and competencies, specific role functions and an interest in clinical outcomes
(Adams, Pelletier, Duffield, Nagy, Crisp & Mitten-Lewis, 1997:220).
Jasper recognises the definition of expert practice as ‘ambiguous and difficult to clarify’
(Jasper, 1994:775). She suggests the concept of expert might be:
A nurse who has developed the capacity for pattern recognition through
high level knowledge and skill, and extensive experience in a specialist
field, and who is identified as such by her peers.
(Jasper, 1994: 774-5)
In this definition the concept of ‘pattern recognition’ is pivotal, and implies harnessing
both knowledge (specialised, practical and theoretical) and experience to think and act
intuitively with a sense of the ‘whole’. Further, that such expertise is recognised and
validated by qualified others (Jasper, 1994:771-773). Sutton and Smith (1995) advance a
similar view that the concept of ‘expert’ has a number of meanings, however they
delineate expert from specialist and advanced nursing practice. They believe expert
practice embraces the practical, technical and situational aspects of nursing practice. Both
knowledge and skill hail from experience that then develops into a particular form of
knowledge that is then applied directly into patient care. Their emphasis of the expert is
in the ‘doing’ of nursing or an ‘immersion in practice’, as opposed to advanced practice
which they believe is ‘qualitatively more than expert practice’, however they contend that
expert practice is integral to an understanding of advanced practice (Sutton & Smith,
1995a:138-9 and Sutton & Smith, 1995b:1038-9).
13
Borbasi (1999:22) uses the terms of expert and advanced practice interchangeably in her
study to ‘ … gain insight into the human experience of specialty bedside nursing and the
meaning specialty nurses ascribe to their world’. Hermeneutic phenomenology was the
methodology employed in this study, actualised by the use of interviewing, journalling
and participant observation. Borbasi identified that more research was needed to
appreciate the contribution ‘senior’ nurses make to the cost and outcome of their care.
Advanced Practice
A broad definition of advanced practice is that it is ‘ … more developed and presumably
better than ordinary practice’ (Pearson, 1984:16). Pearson adds that advanced practice is
essentially ‘being there’ with the patient. He suggests generalists and specialist nurses
can both practice as advanced practitioners. Advanced practice is not dependent upon
specialist nursing skill, however advanced nurse practitioners often have developed
specialist skills in a particular area of interest.
The relationship between specialist, expert and advanced nurse has been investigated, in
detail by Sutton and Smith (1995). They investigated the concept of advanced practice by
directly observing registered nurses interacting with patients, by discussions with
students enrolled in Masters of Nursing (Advanced Practice) programmes and through a
review of the literature (1995b: 1040). Their work has been referred to extensively in this
study because of its contextual relevance and detail. They have provided detail on the
individual terms of expert, specialist and advanced nurse not previously attempted.
14
Furthermore their observations have occurred in an Australian context, which
acknowledges the peculiarities of our health system. They conclude that more ‘data’ is
needed to interpret and extrapolate the meaning of advanced practice before the nursing
profession can acknowledge the contribution of these practitioners.
Sutton & Smith recognise the value of experience-based intuition in Benner’s work, as
this concept leads nurses to challenge their own ‘preconceived notions and theories’
when confronted with ‘actual situations’ in practice (McMillan, 1997:54). They don’t
rely on intuition alone however, as they have the ability to stand back from a situation
and assess the overall impact, as it relates to the patient. It is the way the advanced
practitioner thinks about, sees and experiences nursing that delineates them from the
expert or specialist nurse. An advanced practitioner uses different ways of knowing a
whole experience to guide their practice, and continue to constantly critique their
practice. Their practice incorporates both practical and theoretical knowledge. They seek
excellence and positive outcomes for their patients, and nursing practice is characterised
by clarity of purpose and pragmatic endeavour (Sutton & Smith, 1995b:1040).
A distinguishing feature of Sutton & Smith’s theory on advanced practice is the advanced
practitioner is located ‘in the personal’ (1995b:1038). The personal attributes of the
individual nurse, enhance their advanced practice, by bringing their personal qualities and
humanity to the patient-nurse relationship. Furthermore the advanced practitioner is
‘located in the immediacy of client situations’, which implies an emphasis on the
‘personal’ aspects of the patient-nurse relationship (Sutton & Smith, 1995b:1040).
15
Advanced practitioners are mindful of nursing’s future direction, and contribute to the
development of nursing practice and scholarship within the discipline of nursing by virtue
of remaining primarily focussed on patient care and passionate about providing ‘hands on
care’. Sutton and Smith (1995a:145) claim advanced practitioners demonstrate a
‘reluctance to move away from the direct provision of care to the client’. They claim it is
possible to be both expert and advanced practitioner, whilst expert is the ‘precursor’ to
advanced practice. Most notably, advanced practice is ‘qualitatively more’ than expert
practice (Sutton & Smith, 1995a:139). The characteristics of advanced and expert
practice tend to be more generic in orientation, as opposed to specialist practice that
refers to specific skills applied in a specialised field of nursing.
Specialty Practice
Nurse specialties, incrementally and haphazardly, have contributed to the discussion of
advanced nursing practice. Critical care nursing is one of the few specialties to adapt this
theoretical concept into practice, with the development of their Competency Standards
for Specialist Critical Care Nurses (CACCN, 1995). CACCN (1995:v) declares the
competencies are ‘the gold standard’ of the critical care nurse specialist, acknowledging
that a continuum exists amongst critical care nurse specialists, and that not all nurses will
necessarily achieve this standard. The research methodology undertaken to identify
specialist competencies of critical care nurses, was interpretive in nature. Data was
collected by way of observation, documentary analysis and interview. Themes emerged
from direct observation of specialist level and expert nurses, and by review of critical
16
incidents. Inferences about performance were made and professional judgement about
competence was determined (CACCN, 1995:8-17).
A discussion of advanced competencies is occurring within specialty groups, however
this tends to be in the context of the development of specialist competencies. The
Australian and New Zealand College of Mental Health Nurses (ANZMHN) have
designed Standards of Practice (1995) in which they have specified how mental health
nurses will demonstrate advanced practice by incorporating the six standards within the
areas of: clinical skills, leadership, management, research and education areas, at a level
of excellence. Midwives tend to be focussed on establishing themselves as separate from
nursing; indeed they already consider themselves to be advanced practitioners (Clinton,
Pearson, Dunn, Cheek & McCutcheon, 1999:29-32). The concept of indicators of
‘continuing’ competence has been received by the nursing profession with trepidation;
this is because the original proposal linked ongoing licensure to practise as contingent
upon successful assessment. The intention being that practice would be assessed against
the competencies (Wilkinson, 1998:9). The debate on the issue of continuing competence
is ongoing.
A nursing specialty is a section of the nursing profession that ‘focuses on the health needs
of a defined population’ (Love, 1996:19). The concept of specialisation is applied in a
specific sense to nurse practice, that is specialist nursing knowledge and specialist
nursing practice (Sutton & Smith, 1995).
17
The International Council Of Nurses (ICN, 1992) defined specialisation as a process that
‘deepened and refined nursing practice’, identified by a ‘level of knowledge and skill in a
particular aspect of nursing which is greater than that acquired during the course of basic
nursing education’. ICN called for an orderly development of specialisation by adoption
of a systematic means of determining and designating nurse specialties, setting minimum
standards, establishing regulatory mechanisms and nurse resource planning (Scott,
1998:555-6).
The debate in Australia accelerated after the visit of Dr Margretta Styles in November
1991. Dr Styles advised Australian nurses to aim for an orderly and integrated
development of specialties that would ultimately empower nurses (Parkes, 1994:25).
Specialty practice has been described as located in a field of practice, as a result of formal
education and/or accompanied by experience (Sutton & Smith 1995b:1038). The history
of specialisation is associated with aspects of medical knowledge and skills - those
discarded by medicos. Therefore, specialisation amounts to a maturation process as a
result of an expanding knowledge base. Given that nursing is only now defining its ‘true
essence’ in terms of the accumulation of knowledge, we need to rethink our concept of
specialist nursing practice (Sutton & Smith, 1995a:140-1).
Concern has been raised regarding the risks of deskilling generalist nurses at the hands of
increased specialism in nursing. Risks include the fragmentation of patient care and the
emergence of specialist nurse practice becoming too narrowly focussed (Marshall &
Luffingham, 1998:658-662).
18
Contentious debate also surrounds the issue of credentialling specialist nurses.
Credentialling is defined as the conferring of a credential on an individual nurse by a
process of peer review, in which the highest level of competence is achieved, in contrast
to licensure, which is the minimum standard. Another definition holds that credentialling
is the ‘process by which an individual nurse is designated as having established
professional practice standards, at a specified time, by an agent or body generally
recognised to do so’ (Grealish, 1998:18). This notion raises a number of issues for
consideration in regards to who might gain a credential, the cost, possible over-regulation
of nursing, the method of assessment and the qualification of the assessor (Grealish,
1998:18-9 & Coulthard, 1998:24-5). The issue is far from resolved.
Further controversy surrounds the role of the ‘nurse practitioner’ (NP), who is defined as
a registered nurse educated for advanced practice, the characteristics of which would be
determined by the context in which they practice’ (NSW Nurse Practitioner Review Stage
2, 1993: 3-5). A statement by the National Nursing Organisation believes the NP assesses
and manages particular clinical presentations. The NP is able to do this because of their
‘advanced education’ and specific experience. Their role is context specific and designed
to ‘advance autonomous nursing practice’ across a number of settings (NNO,1998).
Argument emanates from outside the nursing profession mainly because NP’s, in some
contexts, are required to perform tasks formally within the domain of doctors. However
the focus of the nursing role is philosophically different from the medical role (Chiarella,
1998: 30-2). Nurse Practitioners practise in epilepsy management, palliation and cervix
19
screening to name only a few practice settings. Trials are under way to evaluate the
effectiveness of the NP role in suturing wounds and treating uncomplicated fractures for
instance. The results of which will be of relevance to orthopaedic nursing in the future
(Serghis, 1998:7).
Clarification of the role specialty status bears to advanced practice is unclear, and the
literature is divided. Sutton and Smith (1995b: 1040) are quite clear that a distinction
exists between the two levels of practice; not least of which is its ideological premise. In
the case of specialist nurse practice, knowledge generation is limited to a specific area of
practice and has evolved from the medical model, as opposed to advanced practice that
generates knowledge nursologically, with a general application to nursing practice.
Pearson (1984:16) contends that specialism is not necessary for advanced practice, but
often occurs simultaneously. This study will attempt to examine the relationship of
specialty nursing to advanced nursing, by virtue of the perspective the research has taken,
that is an examination of orthopaedic nurse practice, which is of itself a specialty branch
of nursing.
Orthopaedic Nursing Practice
Reference to the American literature is necessary to explicate the role of the orthopaedic
nurse practitioner because little explanation of orthopaedic advanced practice is available
in the Australian literature. Orthopaedic nurses both in the United Kingdom (UK) and the
United States of America (USA) have had their specialty status questioned (Salmond,
20
1996:6). The American experience was in response to ‘downsizing’ of orthopaedic
nursing services. This meant that patients hospitalised with orthopaedic conditions were
found on general medical-surgical areas, which infers the specialty status of orthopaedic
nursing is no longer required. In response to this trend, a study by Love (1996) examined
orthopaedic nursing’s specialty status through the use of a self-administered
questionnaire, which identified seventy six nursing activities. Thirty-six of those nursing
activities were identified as ‘highly orthopaedic’ skills. Nine activities were considered
borderline orthopaedic nursing activities, four of which related to orthopaedic
professional status apparently confusing to the orthopaedic nurses themselves. Eleven
generic activities were identified. Orthopaedic nursing, like any other branch of specialty
nursing, uses an holistic approach to patient care from which the generic activities
emerged (Love, 1996:24). The study recommended results be considered in the design of
orthopaedic nurse education programmes. Salmond (1996) in critiquing Love’s study
called for more research, both empirical and interpretive to overcome the absence of
orthopaedic research in the field, she suggests ‘a log book of critical incidents’ in order to
legitimise the role of specialty orthopaedic nurses. Furthermore she believes research is
needed to ‘… quantify [the] differences in patient care outcomes when cared for by
specialty registered nurses’ (Salmond, 1996:6-7). Similarly Brunner (1998:5) when
considering what is special about orthopaedic nursing recommends the continued use of
clinical exemplars or ‘stories’ as a means to demonstrate the ‘good’ work orthopaedic
nurses do. Harvey and Tveit (1994:45-53) put a strong case for the use of clinical
exemplars to recognise excellence in clinical practice, claiming they define, describe,
validate, preserve, and explain nursing practice in both a professional and personal sense.
21
This study employed clinical exemplars as a means to capture the true nature of advanced
orthopaedic nursing.
One Australian study examining the clinical reasoning of expert and novice orthopaedic
nurses, used verbal protocols and protocol analysis (Greenwood & King, 1995b:907-
913). The study raised some searching issues for orthopaedic nurses and nurses in
general. The study method whilst complex, identified the importance of patient-focussed
care and noted the tendency of specialist areas of nursing to adopt a medical model of
care (Greenwood & King, 1995a:325). Their study’s methodology used observation and
interview techniques, in addition to ‘think aloud’ techniques to examine expert
knowledge and skill (Greenwood & King, 1995b:908-10). Transcription and analysis of
speech provided the material to confirm that the experts in this study knew more than the
novice nurses and therefore could access their knowledge more easily (Greenwood &
King, 1995a:315).
In the USA certification is the credentialling mechanism for the advanced practice nurse
(APN). An APN is a nurse practitioner. They deliver primary and acute care in different
settings. They diagnose and treat medical and surgical conditions and have prescribing
privileges. Certification as a nurse practitioner may require masters degree preparation,
depending on the state, and registering authority concerned. 30% of National Association
of Orthopaedic Nurses (NAON) members are certified (Brunner, 1998:5). Orthopaedic
nurse practitioners have a range of roles and practices, and are found in a number of
settings. Nurses can work from home, ambulatory care settings or in the acute care sector.
22
In orthopaedics specifically, nurses case manage total joint arthroplasty patients pre-
operatively, and manage patients referred with acute musculo-skeletal injuries and long
term orthopaedic problems. Patients are privately referred, self referred or referred via an
emergency department (Pastorino, 1998:68).
Another role is that of orthopaedic trauma coordinator who is associated with a particular
team of orthopaedic surgeons, and oversees their patient’s post operative care including
referral to other specialty clinics. Triage is another aspect of the role, which is undertaken
by phone. Advice is given on fracture management, and management of orthopaedic
problems. Nurse practitioners (NP) are also associated with managing localised musculo-
skeletal problems such as back pain. The NP provides diagnosis and treatment of acute
and chronic musculo-skeletal conditions (Pastorino, 1998:68).
Another example of an orthopaedic nurse clinician (NP), is via the combination of two
areas of nursing practice, orthopaedic knowledge and emergency nursing. Care is
provided for emergency patients presenting with acute orthopaedic problems. The NP
provides care in fracture management, complicated hand injuries, tendon lacerations,
interprets x-rays, applies splints and casts, and removes casts. The NP monitors sedated
patients undergoing fracture reduction, insertion of skeletal traction pins, application of
cervical halo traction or joint aspiration. The NP also provides patient education, mobility
education (eg. crutches) and discharge education and planning. Follow up care is
provided by phone or by out patient visit (Wiseman, 1996:544-5). These descriptions of
orthopaedic nursing roles in America, demonstrate the scope of practice for the
23
orthopaedic nurse practitioner is vast and caters to local needs.
International Experience
Much debate on advanced practice has occurred within the international arena. The role
of the advanced practice nurse has been recognised in the USA for the past 30 years
where a certification process has been in place since 1973. In the USA advanced practice
nurses (APN) work in one of four areas: as clinical nurse specialist, certified nurse
midwife, certified registered nurse anaesthetist or nurse practitioner. Each classification
of nurse must have met the relevant educational and clinical requirements. The American
Nurses’ Association has designed criteria for advanced practice.
They [advanced nurses] conduct comprehensive health assessment,
demonstrate a high level of autonomy and expert skill in the diagnosis
and treatment of complex responses of individual, families and
communities to actual or potential problems. They formulate clinical
decisions to manage acute and chronic illness and promote wellness.
Nurses in advanced practice integrate education, research,
management, leadership and consultation into their clinical role and
function in collegial relationships with nursing peers, physicians and
others who interface with the health environment
(Ball, 1997 cited by Marshall & Luffingham, 1998:659)
Currently American nurses are considering reducing the number of practitioner roles into
a more simplified structure (Castledine, 1998:682). An interstate agreement has been
reached in America that recognises the term Advanced Practitioner Registered Nurse
(APRN) as representing the four categories of Advanced Practice Nurses that currently
exist (Havens, 1999:1). In the United Kingdom significant debate is taking place in
24
response to the emergence of a plethora of roles, however titled, adding to the general
confusion over advanced nursing practice. Nursing practice is divided into three stages
according to the United Kingdom Central Council (UKCC). Professional practice
immediately follows registration. Specialist practice occurs when expertise is gained in a
wide range of settings with specialised knowledge and skills in one or more areas.
Advanced practice is specialised practice in direct patient care, in addition to masters
degree education, clinical skills, research, consultancy and leadership skills. Advanced
practice is currently under review by the UKCC and the nursing profession at large. The
pressure to articulate practice outcomes, to clarify the relationship between varying
spheres of practice, academic levels and professional competence, to clarify the role of
competency assessment in practice, and ascertain the impact of educational arrangements
on future developments, the notion of ‘advanced practice’ and how it is ‘operationalized’
is currently under scrutiny (Scott, 1998:560). Suffice it to say the United Kingdom
Central Council (1994) defines advanced practice as:
Adjusting the boundaries for the development of future practice,
pioneering and developing new roles responsive to changing needs and,
with advancing clinical practice, research, and education, to enrich
professional practice as a whole.
(cited in Marshall & Luffingham, 1998:659)
However the UKCC are moving away from this definition of advanced practice,
preferring to concentrate on the concept of ‘higher level roles in nursing practice’
(Maclaine, 1998:159-163). The latest conceptual statement refers to high level practice in
terms of ‘appropriate knowledge and skill requirements for particular areas of practice
(UKCC, 1998). UK nurses are demanding greater leadership on the issue of what
25
constitutes advanced or ‘high’ level practice.
Compared with our American counterparts, Australia has made little progress towards
defining advanced practice. The debate has progressed to the point whereby a generic
form of advanced competencies exists in addition to the Australian Nursing Council
Incorporated (ANCI) Entry to Practice competencies (1990). The document, Competency
Standards for the Advanced Nurse (McMillan, 1997), published under the auspices of the
Australian Nursing Federation (ANF), in consultation with the National Nursing
Organisations (NNO's) have developed twelve (12) standards which reflect the practice
of the advanced nurse in its totality. The standards project aimed to analyse Benner’s
(1984) levels of nursing practice in the form of competency standards. The project was
mindful of recognising nurses working in specialist and generalist practice settings. This
study confirmed the use of context and narrative as a means to reveal knowledge about
nursing practice, and ‘discriminating amongst different levels of practice’ (McMillan,
1997:55). Through written ‘stories’ and/or exemplars, twelve generic competency
standards were developed during national workshops to assist in analysing the exemplars.
Ongoing clarification of specialist and advanced practice roles is still required, however
McMillan’s work is important to this study because it is contextually Australian,
recognising the peculiarities of Australian nursing practice within the Australian health
system. Interestingly the term ‘advanced clinical practice’ has been enshrined in a recent
industrial agreement. This infers tripartite acceptance of the concept has been reached.
The role is described as being increasingly complex, differentiated by advanced problem
solving and the context in which practice takes place (1998:16). The theoretical work of
26
Benner (1984) largely informed this study, whilst the work of McMillan (1997) heavily
influenced this study.
Summary
Controversy and confusion dominates what constitutes advanced practice. The nurse
practitioner role articulates with the advanced nurse practitioner role (Chiarella, 1998:30).
An advanced nurse practitioner can be either an expert or specialist, although advanced
nursing practice is aligned more closely with expert practice because it incorporates
expert practice more readily. The nurse practitioner appears to ‘evolve’ from expert
practice (Sutton & Smith, 1998:1038). Expert clinical judgement is the result of complex
reasoning and analytical, intellectual processes. ICN recently considered at the
Centennial Conference in London (1999), an international definition of advanced nursing
practice which encompass other classifications of nursing practice including nurse
practitioner. It was agreed the term ‘advanced practice’ become the ‘umbrella term’
under which all other classifications of nursing practice relate (Havens, 1999:1).
Advanced nurse practice is the ‘essence of nursing’, which this study will attempt to
describe and understand.
27
Conclusion
Modern health care is becoming increasingly more complex. This complexity is
characterised by factors such as new health technologies, increased patient complexity
(due to medical, technical and social change) and increased consumer demand. There are
a greater number of legal and ethical dilemmas emerging. A wider range of professional
practice models (case management, primary and team nursing) are being introduced into
health care settings. The nursing profession itself is being placed under greater demand to
overcome such issues as skill shortages and other workforce issues (Scott, 1998;
Grealish, 1998; Serghi, 1998). There are greater expectations placed upon the nurse
practising in this context. Therefore the role of the nurse must reflect the increasing
complexity that exists within the health system. Identifying standards of advanced
practice is an issue the nursing profession is in the process of addressing. Once this is
done the impact advanced practice, however termed, has on patient care can be
ascertained. The debate on advanced practice provides an opportunity to acknowledge
how nursing practice can reflect the ever-increasing complexity within the health system.
This study will attempt to contribute to this debate.
This study will assist in conceptualising advanced practice, particularly in terms of the
nature and scope of advanced orthopaedic nurse practice. I consider conceptualisation a
necessary step before the nursing profession can seriously debate such issues as
regulation of advanced practice, or measure the impact, advanced practice has on patient
care. Consistency in understanding associated terminology would assist immeasurably
with this objective.
28
Chapter 3
Methodology
…It is this chaotic diversity that has attracted men to the world of eucalypts. For here
was a maze of tentative half-words and part-descriptions, constantly expanding and
contracting, almost out of control – a world within the world, but too loosely contained.
It cried out for a ‘system’ of some kind, where order could be imposed on a region of
nature’s unruly endlessness.
This attempt to ‘humanise’ nature by naming its parts has a long and distinguished
history. Once a given subject is broken down into parts, each one identified, named and
placed into groups – the periodic table, strata of minerals, weight divisions of
prizefighters – the whole is given limits and becomes acceptable, or digestible, almost…
(Murray Bail, Eucalyptus)
Introduction
The methodology used in this study was situated in the interpretive paradigm.
Hermeneutic phenomenology was selected because it allowed the meanings of the
phenomenon under investigation that are concealed in everyday actions to be revealed. It
was through thematic analysis and hermeneutic interpretation of subjects' descriptions
that an improved understanding was offered. The phenomenological inquiry undertaken
in this study was informed by the philosophical comtemplation of Heidegger (1962) who
acknowledges that the interpretation of lived experience is inseparable from context.
Hermeneutic interpretation followed the method described by van Manen (1990) and a
meaningful understanding of advanced practice was generated.
29
Heideggerian phenomenology was employed as the methodological philosophy in this
study in order to reveal the meaning of being an advanced orthopaedic nurse practitioner;
whilst hermeneutics provided a philosophical framework in which to interpret the
meaning of being an advanced orthopaedic nurse.
Initially this chapter will provide a working definition of hermeneutic phenomenology. It
is beyond the scope of this thesis to describe the methodological minutiae, given the
breadth of philosophical thought associated with the phenomenological movement,
however, this chapter will attempt to capture the methodological imperatives relevant to
the research question.
This chapter will explore, what Oiler (1982: 178-181) considers the four foundational
features of the phenomenological approach: namely phenomena, reality, subjectivity and
truth. These four perspectives encapsulate why hermeneutic phenomenology was chosen
to pursue the research question. Therefore by way of situating the research question, this
methodological discussion will refer to certain characteristics of Heideggerian
phenomenology which relate to Oiler’s foundational features. The discussion will cover
the essential concepts of Heideggerian phenomenology: of ‘being’ and ‘lifeworld’. A
brief discussion will follow describing the phenomenological differences the literature
alludes to between ‘knowing’ and ‘being’. The discussion will address Heidegger’s ideas
surrounding ‘historicality of understanding’ (Koch, 1995:831). Many of the concepts
discussed in this chapter are inter-related and it is therefore difficult to deal with each in a
discrete sense. Nevertheless this chapter will provide a general overview of Heideggerian
30
Phenomenology and Hermeneutics and conclude with a brief discussion that links
hermeneutic phenomenology and theory generation.
Defining Phenomenology
In its simplest form, phenomenology is the study of a particular phenomenon. Merleau-
Ponty (1964) asserted that phenomenology attempts to describe human experience as
lived (in Oiler, 1982:178). Therefore, phenomenology is the study of lived experience
(Wilkes, 1991:232). According to Gelven, Heideggerian phenomenology is defined as an
…analysis by which the meaning of various ways in which we exist
can be translated from the vague language of everyday existence into
the understandable and explicit language of ontology without
destroying the way in which these meanings manifest themselves to us
in our everyday lives… (Gelven 1989 cited by Walters 1994:137)
Interpretive Phenomenology
The expanded definition of Gelven’s provides the methodological premise upon which
this study is based. Heidegger’s definition refers to hermeneutic phenomenology that
seeks meaning originating from culture: specifically language, practice and the everyday
lived experience (Sorrell & Redmond, 1995:1120). In revealing practices and meanings
one is able to better understand culture. It is the “culture” of the advanced orthopaedic
nurse that this study has investigated. Language, as a mode of expression, acted as a
conduit to the world of the orthopaedic nurse in which certain practices, traditions and
rituals took place. Exploration of the participants’ experiences revealed insights into their
31
world. Similarities and differences within those descriptions, volunteered by the
advanced nurse, conveyed a ‘snapshot’ view of their culture. Consistent with hermeneutic
phenomenology, meanings were extracted that make explicit and attempt to understand
those hidden meanings behind everyday experience and contributes to an appreciation of
what it means to be an advanced orthopaedic nurse. Heideggerian phenomenology
provided an interpretive process that made possible an understanding that emanated from
personal descriptions. Furthermore, interpretive phenomenology provided a philosophical
framework in which to consider the significance of the deeper meaning that the narrative
presented.
Historical Origins
Edmund Husserl (1859 – 1938) is credited as being the founder of the phenomenological
movement. A mathematician by training, he developed a phenomenology that he
anticipated could equally apply to philosophy and science (Cohen, 1987:32). He was
concerned with exploring the phenomena of consciousness. His focus was how the
essence and experience of phenomena ‘appeared’. To Husserl experience was the font of
all knowledge. Husserl believed, in order to study phenomena it was necessary to isolate
them, then subject them to logical inquiry. This style of reductionism included
‘suspending one’s attitude’ toward the phenomenon; that is, completely disconnecting the
phenomenon from its surroundings. The ability to objectify the phenomenon was an
extension of the dominant Cartesian tradition of the ‘mind-body’ dualism. Furthermore
Husserl believed this form of philosophical inquiry could be subject to rigour in the same
32
way the scientific method applied rigour (Cohen, 1987:32; Walker, 1994:136-7).
Husserlian phenomenology described a transcendental phenomenology with an
epistemological inclination, characterised by an ‘immediacy’ of experience. Immediacy
in the sense that the experience was scrutinised at a certain point in time, removed from
its context.
Martin Heidegger (1889 – 1976), a student of Husserl, rejected some of the pr
emises of Husserlian phenomenology. Heidegger believed it was impossible to separate
phenomena from surroundings. Heidegger focussed on what a phenomenon means in
daily existence. This form of phenomenology described an ‘existential phenomenology’
with an ontological inclination whereby understanding comes from ‘being’ in the world
(Koch, 1995:831). It sought to understand the state of ‘being’ and all the relationships
associated with ‘being’. It was characterised by a more contemplative approach.
Contemplative in the sense that reflection of the phenomenon took place cognisant of its
relationship(s) to context.
Heideggerian phenomenology differed from Husserl’s through what Heidegger referred
to as ‘being-in-the-world’. Heidegger argued that the individual is situated and self-
interpreting, that is, he believed that the individual cannot be separated from the context
in which they exist (Leonard, 1989:44 & 7). This was distinct from Husserl, who by
following the Cartesian tradition, attempted to view the individual objectively; that is
disconnected from one’s surroundings (Koch, 1995: 828-9). Neither Husserl nor
Heidegger provided a methodological process per se, but described an approach or school
33
of philosophical thought. As Heidegger (1962:50) stated ‘…phenomenology signifies
primarily a methodological conception…’.
Defining Hermeneutics
Hermeneutics is concerned with understanding and interpretation (Geanellos, 1998:154).
There is a view within the literature that asserts Heideggerian phenomenology is
hermeneutical by virtue of belonging in the world. Heidegger suggests that belonging in
the world is interpretive by its very nature (Ricoeur 1981, cited by Ray in Morse,
1994:121). Heidegger claimed people make sense of their everyday lives, by simply
trying to understand the reason why certain things happen (Walker, 1994:137). Through
textual analysis of actual experience, Chadderton (1997:402) claimed, hermeneutic
philosophy is the way we come to ‘understand’ human existence. ‘Understanding’ is
constituted from our historical, social and cultural domains, therefore it was envisaged
hermeneutic phenomenology would best reveal ‘…the shared practices and common
meanings of the everyday lived experience…’ (Gullickson cited by Crotty, 1997:88). In
order to examine the practice and meaning of everyday life, this study embraced certain
characteristics of hermeneutics suggested by Leonard; with a view to specifically
…understand[ing] everyday skills, practices, and experiences; to find
commonalities in meanings, skills, practices and embodied
experiences… (Leonard, 1989:51)
were applied to the practice of the expert orthopaedic nurse. Consequently this study is
informed by Heideggerian phenomenology (1962) and hermeneutics as espoused by van
34
Manen (1990) with the specific purpose of interpreting the concealed meanings in the
phenomena of the advanced orthopaedic nurse practitioner (Sorrell & Redmond,
1995:1120).
‘Foundational Features’
Phenomena – the ‘things themselves’
Oiler (1982) refers to phenomena in terms of the appearance of objects and events within
the social world. This is an important concept in terms of this study because of the social
nature of nursing. Husserl (1911:80 cited by van Manen 1990:31) and Heidegger (1962)
believed phenomenology meant turning ‘to the things themselves’. Phenomenology is
interested in the daily experiences of people. Impacting upon experience is the social
context in which the experience takes place. Therefore when searching for the meaning
ascribed to the experience of the expert orthopaedic nurse practitioner it was necessary to
consider the location or context in which the phenomenon appeared.
‘Lifeworld’ – the world of lived experience
Phenomenologically, the person is inextricably linked to the world. Our world is imbued
with culture. A synergistic relationship exists between the self and the world (Leonard,
1989:43). The ‘lifeworld’ of the participant refers to the situated experience of the person,
in its totality, (Ashworth, 1997:219) as opposed to how one might perceive it (Jasper,
35
1994: 311). Heidegger (1962) believed that ‘…our primary relationship with ‘things’
is…through lived experience…’ that is, one is ‘engaged’ in some sense (Ashworth,
1997:221). When turning to the ‘things themselves’, one does so in the expectation that
the individual is linked in a rich and complex sense. When ‘lifeworld’ is viewed in this
way it places meaning as contextual and forever changing (Dahlberg & Drew, 1997:311).
Reality
Research paradigms differ according to their view on reality (Jasper, 1994:314). Husserl
searched for reality in the ‘things themselves’ (Crotty, 1996:30); hence Koch claims
‘…reality is the lifeworld…’ (Koch, 1995:828). The reality found within the ‘lifeworld’
is a concept that influenced Heidegger greatly, and is integral to phenomenology. In
phenomenology it is the appearance of reality that is important; reality is subjective and
affected by individual perspective (Oiler,1982:178-9). It is the participant’s perspective
that the phenomenologist is interested in, particularly if there is a degree of commonality
within a number of distinct and unique perspectives. Oiler (1982:179) states ‘…reality is
dependent on individual perspective…’. Rose, Beeby and Parker (1995:1126) claim
phenomenology is an extension of the world-view (or ‘lifeworld’) where reality and
individual experience are inseperable, therefore the ‘inner or subjective reality’ becomes
the phenomenon of interest. It was the perceived reality of each individual advanced
orthopaedic nurse practitioner that this project pursued.
36
Subjectivity
‘Being-in the-world’ refers to experience that becomes meaningful by knowing and
existing in the world. It is this contact with the world that shapes our experience of it. To
reiterate, ‘…knowing shapes experience….’ (Oiler, 1981:179). Heidegger’s discourse
Being and Time (1962) presented the argument that phenomenology is ontological, as
opposed to epistemological. That is to say Heidegger explored ‘understanding’ as a way
of being, not as a way of knowing (Koch, 1995:831). The subjective ‘being’ is pivotal to
this study because the related experiences of advanced practitioners, came from their
subjective reality.
The subjective is further expanded upon by way of background. ‘Historicality’ is a
combination of a person’s background, their ‘preunderstandings’ or perspectives on life
which they have developed through the experience of their life, and the synergistic
relationship of person-world which lends itself to the interpretive nature of human
existence (Koch, 1995:831). Heidegger’s ‘historicality of understanding’ is an
aggregation of the structures and concepts that characterise this specific form of
phenomenology. Nonetheless ‘Heidegger’s ‘hermeneutic circle’ seeks to examine the
relationship these structures and concepts bear to the whole, and vice versa (Chadderton,
1997:402), which will be discussed in the next chapter.
37
Phenomenology: A Critique
‘Credibility’
Credibility is important to the research endeavour. Credibility is perceived in several
ways in qualitative research. In the first instance there is the credibility associated with
the phenomenological text. Cohen and Omery (1994) claim Heidegger believes
credibility is found in ‘being’ (in Morse et al,1994:145). Ashworth (1997:219) supports a
reality whereby essential truths of the human, social world are described. Oiler
(1982:179) states truth is a ‘composite of realities’, implying that each participant’s
reality offers a plausible view. Cohen & Omery (1994), Oiler (1982) and Ashworth
(1997) believe there is a credibility or plausability that emerges from the study of the
trivialities of life, which is in contrast to how positivists would appreciate truth.
The second approach to credibility is associated with the research method. In support of
the notion of credibility in interpretive research, Avis claimed credibility is achieved by
maintaining objectivity (1998:142). For Sandelkowski (1986:27-37) credibility is
associated with ‘rigour’. The positivistic construct of objectivity may not be applicable to
qualitative research, as it imposes restrictions on complex social phenomena, that don’t
abide by such rules. The overall aim of qualitative research ought to be the application of
sound methodological principles, and in this sense objectivity and rigour have merit, if
those principles are followed.
38
In phenomenology the quest to understand meaning not truth is paramount
(Bailey,1997:21). Therefore for the purposes of this study ‘credible’ qualitative research
is associated with all of the above. Credibility for the participants in this study, as
expressed by them, was captured in the text and secondly credibility was also achieved
with the application of a credible method. Arguably credibility in interpretive research is
associated with the participants agreeing with the interpretation and understanding
generated by the researcher (Sandelkowski, 1986:35). Consequently credibiltiy was
achieved when the orthopaedic nurses were able to agree and identify with the
constructed meaning. Finally credibility is demonstrated when the reader clearly follows
the research process from examples contained within the participant’s text, to the
interpretive understanding reached by the researcher.
‘Rigour’
The positivistic notion of ‘rigour’ is contentiously applied to qualitative research,
however, it is not a concept dismissed altogether. Truth and rigour have been
reinterpreted in phenomenological research. Faithfully or honestly representing the
participant’s experience, or their ‘truth’, is a means of achieving rigour in qualitative
research. Being faithful to the description occurs when the individual participant
acknowledges the researcher’s representation as ‘credible’; a term used by Sandelkowski
(1986:30). Credibility or truth is again achieved when others reading the text ‘identify’
with it, as being an experience that resonates, or one they have personally known or
experienced (van Manen, 1990:27).
39
The researcher must be honest and ethical in their approach to the research endeavour. In
phenomenology the researcher must be aware of his/her own ‘pre-understandings’ or
preconceived thoughts towards the phenomenon. It is necessary for the researcher to
acknowledge their own experiences and pre-understandings if they effect the discussion
in some way. Appropriate referencing to the narrative indicates the researcher is being
true to the text. This implies using the participant’s text to support the study’s findings or
themes and arriving at well supported understandings (Koch, 1995:834). Furthermore, a
consistency must exist between the research methodology and the research method and
be obvious enough to enable the reader to critique such a claim (Bailey, 1997:21). The
above has demonstrated there is a place for truth in qualitative research, which rejects
positivistic constructs, on the basis that the research imperative in a human science
paradigm is quite different.
‘Universality’
Dahlberg and Drew (1997: 310-1) refer to the tension between the objectives of
‘uniqueness and sameness’ in phenomenological research. The contradiction emerges as
a result of preserving the ‘uniqueness’ of an individual’s description, yet searching for the
‘sameness’ amongst descriptions of the phenomena under investigation. Ray (1994:124)
poses that theory generation is possible, despite the narrative applying in an isolated
sense to the participants of any one study. Notwithstanding, it is the ‘…unity of meaning
of belongingness and the interconnectedness to the whole of the human condition both
historically and universally…’, (evidenced as essences or themes), which justifies the use
40
of phenomenological description in qualitative research and enriches our knowledge of
human existence.
Methodological Application
The value of phenomenology to nursing knowledge, is it’s ability to bring certain
experiences to light, and therefore through being enlightened, nurses can question or
bring about change in nursing practice. This study is premised in the belief nursing
knowledge is embedded in practice (Benner, 1984). Given the power of phenomenology
to describe the ‘essential meaning of human experience’ (Ray in Morse, 1994:122), the
emergence of theoretical concepts as a result of studying lived experience is possible
(Adam 1987 cited in Rose, et al 1995:1128). Leonard (1989:52) believes the role of
theory in hermeneutics is to identify meaning contained in lived experience. However
van Manen (1990) believes theorising in phenomenology is ‘antithetical’ unless it occurs
in a context of interpretation (Morse, 1994:123&4). Moreover phenomenon can only
demonstrate how and under what circumstances theory is applied, that is phenomenology
guides understanding which is the first step towards development of a theoretical base for
nursing practice. This study will contribute to the collective knowledge of nursing by
presenting a descriptive analysis of nursing knowledge embedded in orthopaedic nursing
practice.
41
Nursing and Phenomenology
The literature resonates with the suitability of phenomenology to nursing. Nursing is
essentially a social practice by virtue of the social interaction that takes place within the
patient–nurse relationship. Taylor states “…nursing occurs in the ‘real world of
practice’…” (1993:171) characterised by holistic and caring practices; practices difficult
to objectively quantify. Nursing is constructed through language (Walsh, 1996: 234) and
our understanding of the world is revealed through the use of language (Mitchell,
1994:227). Social practices, which contribute to our understanding of the world, contain
interpretations and meanings. Given that the focus of this study is to reveal the meaning
and human dimension of experience, traditional scientific methods are poorly equipped to
fully capture and explain this phenomena. Phenomenologists and nurses alike, recognise
and value the importance of ‘…observation, interviews, interaction and interpersonal
relationships…’, in what they do (Rose et al, 1995:1127).
The use of interpretive phenomenology for this study will preserve the uniqueness of the
experience and provide an ontological understanding of what it means to be an advanced
orthopaedic nurse practitioner. This study will therefore concentrate on the ‘meaning and
significance’ of advanced orthopaedic nurse practice. This personal perspective is
important to fully appreciate advanced practice. The research approach of interpretive
phenomenology is particularly focused on making visible an interpretation of experience
as it is lived in everyday nursing practice. Phenomenologists believe meanings and
interpretation are contained within social practice. Phenomenologists are interested in
understanding meanings of human action (Avis, 1998:143). The phenomenon of interest
42
in nursing is the daily life of the people they care for. The practical domain of the nurse is
multi-dimensional and complex. Advanced nurses perform in a particular way within this
environment. To what extent this occurs is not immediately apparent. This study aims to
uncover elements of advanced practice that would otherwise be hidden, and therefore
identify the significant impact advanced practice has on the nurse-patient relationship.
This study utilised a methodology sensitive to revealing meaning and experience from a
personal perspective so that the study findings make a difference in the lives of the
participants, orthopaedic nurses, advanced practitioners, other interested nurses and most
importantly their patients.
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Chapter 4
Method
Introduction
This chapter will describe the actual method and process undertaken in this study. The
phenomenological method, per se, was not articulated by the early philosophers. It is the
philosophical premise that guides the research method. The task of prescribing the detail
of method was taken up by the likes of Colaizzi (1978), Giorgi (1975&9), van Kaam
(1966) and Crotty (1996:158-9). This project is informed by the method designed by Max
van Manen (1990). van Manen’s approach allows the researcher to modify the method to
suit the research question. This chapter will begin by elaborating upon his six steps in
making an hermeneutical phenomenological interpretation and expand upon those
methods chosen for this study. The discussion will elaborate upon the study context in
terms of orthopaedic nurse practice; the nurse participants and how their descriptions of
advanced practice were captured. This chapter will incorporate within the discussion an
explanation of the role of language; the process of interpretive analysis and how a
dialogue with the text was established via the hermeneutic circle.
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Van Manen’s Method
1. Turning to the Phenomenon of Lived Experience
According to van Manen the first stage in conducting human science research is to turn to
the phenomenon. For him phenomenological research focuses absolutely on lived
experience. The phenomenological endeavour aims to transform the lived experience into
its essential structure, and in this way the lived experience gains renewed meaning. Van
Manen notes a researcher is already oriented or connected to the phenomenon by
possessing a certain interest in the phenomenon (van Manen, 1990:31, 35-41).
In this study I am oriented to the phenomenon by virtue of being a nurse with a passion
for orthopaedic nursing, an advanced practitioner, and a student of nursing. The study
participants were asked to recall an experience in which they considered they performed
as advanced orthopaedic practitioners, and as the researcher I acknowledged it was their
interpretation of the experience. The role of the researcher was to tease out the
meaningful aspects of the experience in such a way that using the following steps in van
Manen’s method could ‘…construct a possible interpretation of the nature of a certain
human experience…’ (van Manen, 1990:41). In this instance creating the researcher’s
interpretation of advanced orthopaedic nursing practice.
45
2. Investigating Experience as We Live It
Our recollection of an experience can alter from the way in which it was originally
perceived; by virtue of its ‘transformation’ into the spoken form (van Manen, 1990:54).
This is the distinction van Manen makes when addressing the ‘nature of data’. Collecting
data or ‘lived experience material’ is achieved by either interview/conversation, in
writing or by observation. The aim of the investigation is to become ‘…full of the world,
full of lived experience…’ (van Manen, 1990:32).
Through the act of conveying the experience, the lived experience has already been
filtered, and constitutes an ‘interpretation’ of the original experience as lived. van Manen
comments that the ‘personal lived description’ does not equate to a phenomenological
description however. This occurs after a period of reflection when the special meaning of
the experience is known. The phenomenologist is interested in the potential for
universality, contained within the phenomenon (van Manen, 1990:53-8). The source of
phenomenological experiential description can include: written description, interview/
‘personal life stories’, observation, literature, biographies, diaries, journals and art.
Importantly the overriding goal of obtaining interpretive meaning of the experience must
remain paramount, regardless of the source.
I asked the orthopaedic nurses to describe an experience, whereupon they drew on
advanced practice skills. The collection of ‘personal life stories’ retold through the
interview/conversation with the researcher, provided an entrée into their world and
enabled me to derive interpretive meaning from a previously lived experience.
46
3. Hermeneutical Phenomenological Reflection
This step of van Manen’s method follows contemplation of and making apparent the
essential themes or meanings of the phenomenon. van Manen (1990:77) claims this
requires reflection, clarification and an explanation of the structure of the meaning of the
lived experience. Total immersion in the data is the process of the researcher becoming
intimately familiar with the experience as lived. Through familiarity, the
phenomenological themes will become apparent as the ‘structure of experience’ (van
Manen, 1990:79). ‘(O)pening up’ to the deeper meaning of the experiential account, leads
the researcher to thematic development. Articulation of themes serves as the stepping
stones to deeper meaning. Themes encapsulate the core of the notion and give meaning
and understanding to the phenomenon of interest (van Manen, 1990:88).
van Manen suggests thematic discovery occurs as a result of either ‘sentencing’,
‘highlighting’ or ‘detailing’ the text. These techniques are aimed at uncovering or
isolating aspects of the phenomenon within the text. When using the ‘sententious
approach’ the aim is to capture the meaning of the phenomenon as a whole. The detailed
or line-by-line approach’ examines each line of the text to identify what each sentence
reveals about the phenomenon of interest (van Manen, 1990:93). In this study selective
highlighting was chosen as a means to identify themes. During initial and subsequent
reading and listening, I identified significant words or phrases within the written texts. As
concepts emerged, I re-read the descriptions searching for examples of phenomenological
meaning.
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4. Hermeneutic Phenomenological Writing
The next step was to create a ‘linguistic transformation’ (Van Manen, 1990:96). This
continues the process of interpretation via language. Language brings the human
experience to life, as it were (van Manen, 1990:38). Hans Georg Gadamer (1975) a
student of Heidegger, progressed the notion that human understanding occurs through
language and tradition (Walsh, 1996:234). Thompson (1990) believes the link between
language and cultural practices, confirms the existential view that a world through
language exists (Walker, 1994:139). Heideggerian phenomenology, and therefore
language, was used in this study because ‘…language is sensitive to common human
experience…’ (Avis, 1998:143). Mitchell adds language reveals different realities; the
realities of this study’s participants is the source of the hermeneutic phenomenological
text. The participant’s experiences of advanced orthopaedic nursing practice are
summarised in chapter five of this thesis. After thematic analysis certain themes were
identified that describe the experience of advanced orthopaedic nurse practice for those
nurses. Chapter six will exemplify these themes.
5. Maintaining a Strong and Oriented Relation to the Phenomenon
van Manen cautions the researcher to remain strong and oriented to the phenomena in
question and not to become side-tracked or preoccupied with self-interested reflections
(van Manen, 1990:33). As a result of appropriate researcher orientation, understandings,
interpretations and formulations should be produced that are true to the participants’
texts.
48
I maintained a strong and oriented approach to the phenomenon by declaring my pre-
understandings; subjected myself to interview conditions in order to identify with the
participants’ experience of interview; developed a rapport with each participant; utilised
an open interview style, characterised by active listening techniques. Each technique was
employed so that the stories came to me in an unadulterated way.
6. Considering Parts and Whole: the Hermeneutic Circle
The hermeneutic circle of understanding is a metaphor to describe the process of moving
between the parts (each individual participant’s experience) and the whole (made up of
all the participants’ stories of the phenomenon) during the interpretation process (Walker,
1994:138). It is a continual movement; a constant back and forth motion, that examines
the relationship the parts bear to the whole and vice versa. Leonard suggests this
systematic analysis of the whole produces deeper understanding, which then assists re-
examination of parts, and then re-examination of the whole, in light of the understanding
gained. This process continues until the fullest understanding possible, is reached by the
researcher (Leonard, 1989:51).
The hermeneutic circle has no true beginning to understanding, and in a way is analogous
to the ‘chicken and egg’ scenario, because of the interdependent relationship between the
‘parts and whole’ (Geanellos,1998:159). The concept of parts and whole operates on a
number of levels. In terms of the study design a balance must be achieved between the
parts of the text and the overall textual structure (van Manen, 1990:33). In terms of the
49
narrative, congruency between the essences and the phenomenon should be achieved and
the individual participant and the participant group.
The hermeneutic circle is a combination of a person’s background (meanings, skills,
practices), co constitution (person-world concept) and pre-understandings
(preconceptions/prejudices) where understanding is found. See Diagram 1.
Diagram 1 - The Hermeneutic Circle of Understanding
Imagine viewing this diagram through the lens of a camera. Hermeneutic interpretation
occurs through a constant movement of the focus mechanism, back and forth. You may
want to focus on separate parts, or the whole. Understanding emerges when the
relationship of each part, to the other becomes clear.
pre-understandings
co-constitution
background
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A good application of the hermeneutic circle relies on the ability of the researcher to use
their own experience and background to develop rapport with the participants (Koch;
1996: 179). Rapport began with the participants well before the study was underway by
virtue of a history between the researcher and each participant, established through our
working relationship. I respected each participant in a professional sense. Some I had
worked with more closely than others, however we all shared orthopaedic nursing in
common. It was through the shared experience of collegiality that rapport was
established. Moreover it assisted in extending the rapport to the interview process. It was
imperative that every participant felt comfortable throughout the interview process, in
order to optimise the experience for all concerned.
Study Context
This study was premised by a strong belief in the influence of context; as Leonard
(1989:46) attests:
…to understand a person’s behaviour or expressions, one has to study
the person in context, for it is only there that what a person values and
finds significant is visible…
A rich description of context was provided so that the reader could personally reconstruct
the research description in their own mind, and live it again, as it were.
The context of this study was the orthopaedic and trauma unit of a busy, metropolitan,
public hospital. The unit is divided into four wards. The mission of this unit is the
achievement of excellence in musculo-skeletal medicine. The unit’s core business is a
51
combination of elective surgery, trauma management and orthopaedic rehabilitation The
patient population encompasses a broad range of ages. The study participants were all
recruited from the orthopaedic service area of this institution.
The Participants
Permission was granted to approach members of the nursing staff by the Director of
Nursing. Participant numbers in phenomenological research are typically small as large
volumes of data are generated requiring in depth analysis. I therefore invited seven nurses
to participate in this study, and all agreed. I believed each nurse participant demonstrated
advanced practice in orthopaedic nursing according to Benner’s description of ‘expert’
(1984:31-38). All of the participants, but one, possessed a post basic qualification in
orthopaedic nursing, and all had at least five years post basic experience in nursing. The
nurse not possessing an orthopaedic certificate had extensive experience in orthopaedic
/trauma management and nursing practice. Of those who had formal orthopaedic
qualifications, five had obtained hospital certificates, and one had acquired a post
graduate diploma. Amongst the participant group, clinical, education and management
nursing functions were represented. One male was interviewed the remaining were
female.
The researcher and one other participant were not practising nursing at the time of
interview. All but two participants were interviewed in the setting in which they
practised, however of those nurses, only one was ‘on duty’ at the time, but interviewed
52
away from the direct practice setting. The other nurses were interviewed in their own
homes, a venue mutually agreed upon by participant and researcher.
The Researcher
The researcher was considered the eighth participant. I am an orthopaedic nurse working
in the unit and possess both a hospital certificate and a post graduate qualification in
orthopaedic nursing. I would describe myself as possessing a passion for orthopaedic
nursing. I have more than five years post basic experience in orthopaedic nursing and had
some experience in a promotional position. Moreover I have an ‘abiding’ interest in
advanced practice which had evolved from an awareness of the general debate occurring
within the profession. The question remained in my mind: How did the concept of
advanced practice translate to orthopaedic nursing? What was the formal status of
advanced practice competencies in orthopaedic nurse practice? How were orthopaedic
nurses engaged in the debate?
Orthopaedic Nursing
Advancement in orthopaedic surgical techniques means the nature of orthopaedic nursing
has changed dramatically over the past decade. It could be said orthopaedic nursing is ‘a
dying art’. The specialty appears to be experiencing a ‘crisis of confidence’ evidenced by
the lack of interest in the orthopaedic nurse special interest group. The state association is
currently in a state of abeyance and is run by a passionate few. The national body is
53
fragmented and the states rarely communicate with each other. Post graduate courses
offered by universities in orthopaedic nursing have struggled to attract enrolments in the
past. Despite this, you will often hear nurses say of orthopaedic nursing ‘…you either
love it or you hate it…’. The nursing work is very physical in nature, by virtue of the
patient’s physical disability and impairment to mobility. The overriding aim of
orthopaedic nursing is the restoration of musculo-skeletal function. The challenge to
nurse this diverse age group, together with the physical nature of orthopaedic nursing,
means an atmosphere of camaraderie amongst the nursing staff exists. Teamwork is
essential. Good team dynamics rely on each member performing a different role. I was
interested in the advanced practice role. I wanted to know how it related to orthopaedic
nursing.
Ethics
In this study ethical conduct relied on protecting the rights of participants and respecting
their human dignity. Permission to conduct the study was sought from the Director of
Nursing. The study was reviewed by the Research and Higher Degrees sub-committee of
The University of Adelaide for soundness in approach. Ethical approval was obtained
from the hospital’s ethics committee chairperson on the basis of the following:
Participants were invited to join the study; inclusion was voluntary. Explanation of the
aims of the study was conveyed to each participant, along with the expected level of
commitment in a plain language statement (see Appendix 1). Informed consent was
obtained prior to each interview (see Appendix 2). A provision for the participant to
54
withdraw from the study at any time was guaranteed. Where possible, the researcher
verified each participant's narrative by returning to the individual concerned, and seeking
their approval that the researcher had captured accurately what the participant wanted to
say about the phenomenon. The researcher did, as a courtesy, feedback the results of the
study to each participant. Privacy, confidentiality, and anonymity were qualities this
study embraced by protecting and securing the text by the non identification of
participants within the study report. Any references to colleagues and workplace were
deleted from the transcript. Security of text (ie. tapes, transcripts and consent forms) was
guaranteed by ensuring they are stored in a locked cupboard at the researcher's home.
Narrative text will be secured in this manner for at least five (5) years.
Descriptions
A phenomenological interview is more of a conversation aimed at encouraging the
participant to tell a story about the phenomena under investigation. The aim of the
interview was to elicit a rich description of the phenomenon. The descriptions came forth
in response to the question ‘Please describe a situation in which you believed you
performed at an advanced level. Please disclose all your thoughts, feelings and
perceptions until you can think of nothing more to say’. Throughout the interview the
researcher asked questions to seek depth and clarity from the participants. It was
important to establish a context to the episode, therefore the participant was asked to
think back and recall the time of the experience, who else was present, and the activity
level of the ward.
55
It was important that a vibrant picture of the lived experience was recreated in every
detail. At all times, the researcher employed, active listening techniques in order to
‘connect’ with the participant and share their experience anew. The researcher made
agreement noises wherever possible, laughed with the participant where appropriate,
nodded and actively participated in the recounting of the incident through body language
and hand gestures. Participants were made to feel comfortable at the commencement of
the interview, by first describing their professional nursing history. By the time the
research question was asked, the participants were familiar with the interview conditions
and a rapport with the interviewer was established. Each participant was given the chance
to think about a situation in private. Some participants required extra time to do so. The
remaining participants had an experience that immediately came to mind. The
participants retold their experience virtually uninterrupted in the first instance, unless the
researcher sought immediate clarification of a particular fact. The researcher then asked
questions in order to ‘appreciate’ further the situation being described. The interview
therefore:
… evolved as a dialogue in which the nurse and the researcher together
focussed and explored the meaning of nurses’ work …
(Fagermoen, 1997:437)
An unstructured, interview format was adopted. Descriptions were collected by taped,
‘face-to-face’ interviews, conducted by the researcher. One interview exceeded one hour.
There was a total of seven hours of interview recorded. Each interview was transcribed
verbatim following tape recording. Coding and/or referencing of the text took place by
way of firstly identifying the participant with a randomly ascribed name then followed by
56
the numbered lines from the text. For example two lines of text from Anne’s transcript
were referenced as (A: 2-3).
Journal
A journal was maintained, by the researcher, throughout the interview process, during the
period of transcription and until the last phase of interpretation (writing); that is over a
period of ten months. The journal assisted in enriching the context in which the
interviews took place (Koch, 1996:178). An entry was made prior to the first interview
that discussed the researchers’ feelings approaching the initial interview. Following each
interview an entry summarising the process of both participant and researcher interaction
was made. This began the process of reflection that was to follow (Koch, 1994:977).
Similarly fieldnotes were coded to facilitate referencing to the text. Fieldnote references
took the form of (fldnte:1), meaning: fieldnote, page 1.
Interpretive Analysis
The verbatim transcripts formed the basis for textual and thematic analysis. Additionally,
journal entries provided another source of text. Interpretation emanated from the
meanings contained within the narrative text. During analysis it was important to remain
oriented to the text and not pre-empt interpretation, although, the process of reflection
began when I first listened to the tapes for analysis.
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Hermeneutic analysis occurred in three stages as suggested by Leonard (1989:54). After
checking for accuracy each individual description was read several times to get a broad
‘feel’ for the text. When each description was read this way, a mechanism of highlighting
the themes emerged, beginning with noting significant words or phrases. This method
was applied when returning to each description and searching for similar words, phrases
and ultimately themes in accordance with van Manen’s style of selective highlighting
(1990:94). So for the second stage of analysis, and with a sense of the themes, I returned
to the descriptions and searched for examples of themes ‘in action’; that captured the
meaning in a concentrated form and coded them accordingly. The third and final stage of
analysis included the search for strong representations or ‘patterns of meanings’,
otherwise referred to as paradigm cases. A paradigm case or exemplar is an experience
that stands out sufficiently that it is used as a reference point for subsequent situations the
participant, or nurse, may encounter (Benner, 1984:8). These examples served as a means
to preserve the integrity of the text. Commonality and differences amongst the
participants’ descriptions were identified.
‘… Interpretation is an attempt to grasp and recreate meaning in order that more complete
or different understandings occur; it seeks to bring to light, that which is fragmentary,
confused or hidden….’ (Taylor 1971 cited by Geanellos 1998:155). The interpretive
account describes and explains how the understanding is generated (Geanellos,
1998:155). Organisation of themes and examples that clarified meaning were organised
into the study report that served as the phenomenological text.
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Interpretation for this study concluded when the study results were written up, however
‘…[h]ermeneutically, interpretation is never final or complete, it is always an
approximation…’ (Geanellos, 1998:158). This study provides the best approximation
possible at the time. Notwithstanding, the text and the possibility of ongoing
interpretation lives on in the reader.
Hermeneutic Circle
The hermeneutic circle began by recognising my own background, preunderstandings
and connection to the world and the phenomenon. Initially this was documented in the
journal and declared in chapter one. Movement between the parts (the participant’s
experience) and whole occurred continually throughout analysis of the descriptions as
previously described.
Dialogue with the Text
A dialogue with the text was established through total immersion in the stories told by the
participants. By concurrently listening and re-reading the text, I dwelt in the data up to
the point that I could hear the participant’s voice in my head when I read their narrative,
until meaning and understandings emerged.
59
Writing
‘…[H]ermeneutic phenomenological research is fundamentally a writing activity…’ (van
Manen, 1990:7). The process of writing added another dimension to interpretation by
revisiting the incidents over. The creation of a ‘linguistic transformation’ has been
described above.
Conclusion
This chapter has described the process undertaken by the researcher to study the
phenomenon of advanced orthopaedic nursing practice. As van Manen claims ‘…a real
understanding of phenomenology can only be accomplished by actively doing it’ (van
Manen, 1990:8). This study provides a glimpse into the ‘lifeworld’ of seven orthopaedic
nurse practitioners. The incidents described were tape recorded, transcribed and then
subject of interpretive analysis. The hermeneutic principle of ‘dialogue with the text’ via
the ‘hermeneutic circle’, was applied, and a new understanding of what it means to be an
advanced orthopaedic nurse practitioner emerged. Furthermore this study represents my
own personal journey wherein I discovered what advanced practice means to me.
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Chapter 5
The Narrative Text
…Story: a narration of the events in the life of a person or the existence
of a thing, or such events as a subject for narration…
(The Concise Macquarie Dictionary, 1988:1268)
Introduction
Storytelling has been a custom embraced by many societies as a means to convey its
history and inform the young of its cultural origins and traditions as they’ve evolved over
time; such as the dreamtime stories of the Australian aborigines. Phenomenology
embraces the process of storytelling and elevates it to an art form; in so much as it
provides the means to celebrate the ordinariness of everyday life.
Heideggerian phenomenology views text as data (Koch, 1996:78). In this study seven
nurses provided a glimpse into the everyday life of advanced orthopaedic practice. The
seven incidents described by these nurses comprised the ‘narrative text’ that forms the
body of this thesis.
The participants represented a mixed group of advanced practitioners in terms of years of
experience and positions held. The participants involved in this study were expected to
capture the breadth of advanced practice that exists in this unit. Each individual
participant was asked ‘Why did you choose this as an example of advanced practice?’
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The following descriptions provide insights into their beliefs about the world of
orthopaedic advanced practice. This chapter will take each interview and create a
description of the event each participant chose to share. An appreciation of the
uniqueness of these nurses and their orthopaedic nursing practice will therefore emerge as
the context of each event is revealed.
Di
Di described an incident that occurred upon her return from leave, in which an elderly
woman allocated to the other end of the ward suffered a post-operative, cardiac and
respiratory arrest. Di knew the patient and her relatives from a previous admission.
During her conversation with the relatives another member of the nursing staff
approached Di requesting her urgent attention:
An enrolled [nurse] came and got me [because] they needed a hand in
the toilet; And she [the patient in the toilet] had fainted; that had
become non responsive and was obstructing her airway. And when I
got there the nursing staff member was trying to maintain her airway
but without supporting her spinal fusion … (D: 62-66)
Di, being the most senior nurse on the ward, immediately took charge of the situation.
With assistance she moved the patient to the ground whilst maintaining spinal alignment,
and noticed the patient ‘… wasn’t breathing and (she) had no carotid pulse … ’ (D:68-
69); she instructed someone to ring the emergency number; and ‘screamed’ for the
emergency trolley; she then gave the patient ‘a big breath and she responded’ (D: 71-77).
Di remained with the patient after she was transferred to bed. She administered oxygen;
62
made sure her observations were stable; organised an Electrocardiograph (ECG) to be
taken; set up an intravenous drip and generally assessed and observed the patient (D:91-
93). Meanwhile Di was wondering where the emergency team was. The junior nurse
responsible for calling the emergency phone number had not specified ‘cardiac arrest’
when making the emergency call, and subsequently the resuscitation team had not
arrived. The medical intern however was present. Di expressed (several times throughout
the interview), some concern over the medical intern’s management of the situation:
Like I’d never met this intern before. But within a five second decision
I’d have decided that he was incompetent because he wasn’t worried
about her venous access, he wanted a postural B/P [blood pressure].
And that wasn’t my primary … That wasn’t the train of thought that I
had … But I saw her, I knew that she had stopped breathing, I knew
that she had no carotid [pulse], because I was the one feeling for it and
I couldn’t find it… (D:222-228)
The significant issue for this nurse, from an orthopaedic perspective, was the fact the
patient was recovering from surgery to her cervical spine. She was concerned that during
the resuscitation process there did not appear to be consideration of the patient’s
underlying orthopaedic condition (spinal fusion). Di acknowledged surviving this acute
event was the current priority but felt consideration and care for the patient’s underlying
condition should not have been forgotten, that is, preserving the integrity of the spinal
fusion. The nurse registered surprise that only she seemed to consider the potential
damage.
… nobody else around me had any idea of what was going on. Like
they just didn’t even think about her orthopaedic injuries, they were
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more concerned about her airway which, yeah sure it’s her primary
concern, but she was breathing and she was responding… (D: 80-83)
The incident required this nurse to draw on many clinical skills. Not only did she attend
to the patients physical needs, but made time during the incident to provide reassurance
to the family members:
Like I just, in a spare obvious two minutes, [ironic laughter] I went
down there and reassured them that she was okay … I just reassured
them that she was alright, and that she was responding. (D234-239)
Di was very much aware of the impact the situation had had on the junior staff members.
She recalled:
I’ve got to think, (I got), to remember to speak to that enrolled [nurse]
about what happened and to the student [nurse]… (D:342-343)
She described in detail the debriefing, support and education she provided to nursing staff
throughout the shift. At a later date Di felt it was necessary to report this incident to the
Clinical Nurse Consultant (CNC). During this discussion she highlighted issues of
concern in relation to a deficit in some staff’s knowledge of nursing spinal injury patients
and associated bowel care, and the poor skill mix that was occasionally evident on
weekends in this ward.
Di displayed in her interview a cognisance of, and an ability to, manage the ward
situation. Di attended to the care of this patient and reallocated staff to care for her
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patients at the other end of the ward. She had a lot on her mind and was doing, and
thinking of several things at once.
… I was thinking at two hundred miles an hour. I was already thinking
of what was going on with the patient. I was thinking about the fact that
I’d left twelve patients at my end of the ward unattended, so I was
prompting my junior staff to make sure they were okay and to start
settling them. (D:325-328)
By the end of the shift Di had everything under control. The patient’s condition was
stable. She’d checked that the drug rounds had been done, other patients were settled, ‘…
and I knew everything was up to date, yeah at both ends. Then I took the enrolled [nurse]
aside’ (D:314-315) to discuss the situation that had occurred and ascertain how she felt
she handled the situation. Despite the unprecedented emergency situation that had
occurred, the other patients in the ward had not been neglected and all staff on the ward
completed their allotted duties and left on time.
When I asked how she felt about the situation, Di made two points: The first was. ‘I umm
felt competent and I felt that we’d done a good job’ (D:349); The second point she raised
was in relation to her role as a nurse during the cardiopulmonary arrest:
…[pause] I felt a bit guilty.
Anita: Why’s that?
Because it’s always been that nurses are not, not there to call the shots
on what happens. They are not the people that make the decisions and
the medical staff are responsible for that and that we should answer to
them. But in this situation I wasn’t answering to anybody. The nursing
staff were the ones in control of the situation. (D:355-361).
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Di’s management of the ward situation was orderly, routine, almost second nature.
Thankfully the patient survived the event. Di remarked upon reflection - ‘that’s good
nursing’ (D367). Di felt rewarded when the patient was discharged two days later and
commented on the family’s reaction to her:
… I’m sure that the family appreciated, like I had no hesitation in
thinking that the family appreciated everything we did. And the patient
thanked us and kissed our hand as well and was so grateful and that
was a rewarding feeling like, a positive feeling and it made you think
that’s what I’m here for, that feeling. (D:370-374)
The thing Di remembered most about the incident was the possibility that the outcome
could have been far worse.
Or just maybe the potential if we didn’t have that orthopaedic
knowledge, the potential complications is what I thought of afterwards
… we could have done more damage than good. (D: 413-417)
Gina
Gina’s nursing role in the orthopaedic nursing service was as a case manager, which
incorporated supervision and responsibility for clinical care and broader multi-
disciplinary coordination. Usually she was the first health worker, patients awaiting joint
reconstructive surgery, would come into contact with. The patient would arrive in pre-
admission clinic for examination and education prior to their surgery. At this first, pre-
operative appointment, Gina would routinely obtain a medical history, perform an
orthopaedic examination and assessment, and initiate discharge planning. Gina recounted
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a recent experience of just such an appointment in which she detected a previously
undiagnosed, medical condition.
The patient presented with a history, in the last six to eight months, of occasional,
nocturnal, central chest pain and shortness of breath during the day (G: 35-38).
I suspected that it could be angina type symptoms. She wasn’t
complaining of any other sort of symptoms and I thought it was
necessary to get this investigated before she was due to come in and
have her operation. (G:40-42)
Gina proceeded with the examination but prepared the patient, on the basis of her
findings. She informed the patient she would probably be referred to a cardiologist
(G:157-158). She advised the operation may be delayed, her recovery may be slower and
discharge delayed because of her medical problem (G452-454).
The patient, an elderly woman in her eighties, appeared ‘quite healthy’. The orthopaedic
assessment revealed the patient had been experiencing severe osteoarthritic pain in the
affected knee over the past five years. Her mobility was poor, characterised by a
noticeable limp and reliance on a walking stick. She had a noticeable leg length
discrepancy and valgus deformity (bow-legged) of her lower leg. There was poor
extension and flexion in the knee and limited range of movement (G:52-54; 186-197).
Even when she just stood up onto the one step to get on to the weighing
machine, she struggled quite badly with that two or three inch step. So
she was pretty limited in what she could do, I think. (G: 212-215)
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Based on the medical history, orthopaedic assessment, and investigation of this patient’s
social situation, Gina predicted this patient’s post-operative recovery would progress
slowly, requiring an extended length of stay and rehabilitation.
Looking at her, it is amazing how quickly you get to judge people
[laughs] You can pick off the head probably nine times out of ten, the
ones you think are going to get up out of bed and progress according to
plan and go home with minimal supports and that type of thing. And the
ones that are probably going to need a little bit longer or extended
rehab or you know that they are going to struggle at home.
(G:217-221)
Angina was provisionally diagnosed by the anaesthetist in clinic that day. Afterwards
Gina spoke to the orthopaedic registrar who would make the ultimate decision about
whether this patient would proceed for joint replacement surgery. In uncomplicated cases
Gina would decide ‘about the order in which we operate on people’ (G330-331). She
considered this a fairly responsible task.
At the interview Gina struggled to find an incident to recount. Eventually she chose
something that had happened the previous day. She appeared to be in a reflective mood
throughout the interview, preferring to generalise about her duties, rather than providing
specific detail. She provided a lot of detail about her role emphasising the routine
education of patients (fldnte:11-12). In describing her thoughts on advanced practice
Gina focussed on education and knowledge:
Not just specific orthopaedic knowledge, but also that higher level of
orthopaedic knowledge that I have got as well. On the ward nurses
don’t necessarily do a complete orthopaedic assessment on range of
motion and joint function and I have been taught how to do that in the
ortho [paedic] course and also by doing this job. (G: 585-589)
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Furthermore Gina focussed on her ability to make decisions and pointed to the level of
interaction she had within the multi-disciplinary team regarding patient care, as
something that gave her personal satisfaction:
It [the job] allows me to make decisions above what you’d be doing on
the ward. And I really, really find it rewarding to be able to interact
with the doctors on such a one-to-one level which you don’t necessarily
get on the ward as well. (G: 589-592)
Gina mentioned several times during the interview how important the ability to make
decisions and act on those decisions was to her. In this recollection, the decision to book
the patient in for a cardiology review and follow up the results; the modifying of her pre-
operative education in response to the patient’s medical history; and the discharge
planning she implemented following her inquiries, generally left her feeling satisfied:
… I was pretty confident that we did a thorough assessment of her [the
patient] and identified relevant issues with regards to her discharge
planning and also her medical needs …
(G:570-572)
I was left with the impression Gina was confident the assessment had gone ‘pretty well’
(G:582) and that over time, in the position of case manager, her professional confidence
had grown.
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Ellen
Ellen described a situation which occurred some years ago, where she believed patient
care was compromised due to the incorrect application of Hamilton Russell traction. The
elderly male patient had suffered a traumatic fractured neck of femur and the purpose of
traction in this instance was to provide pain relief from muscle spasm and also apply
traction to approximate the fracture fragments. This nurse was compelled to act in a
situation she found herself confronted with. It was immediately obvious to Ellen as soon
as she arrived on the ward that morning that the patient’s traction had not been applied
correctly and had become dysfunctional.
… as a quick overview I saw it as a pressing thing that needed to be
done and I suppose my concern was knowing the nurse, umm, that I
could see that it could really get to the end of the shift, until the lates
[afternoon shift] come on before something for this patient’s traction
[was done] which was another few hours. (E:187-191)
Furthermore Ellen was concerned with the patient’s level of discomfort. Her quick
assessment of the patient confirmed her original observations. The ward wasn’t unduly
busy so Ellen turned what she perceived as a problem with nursing care, into an
educational opportunity for the nurse responsible for delivering care to this patient. She
and the nurse reviewed the traction apparatus. The nurse was unable to demonstrate a
working knowledge of the principles of traction and did not detect any problem despite
‘the bandages were all slipped down and the weight was resting on the ground’ (E: 82-
83). Ellen was ‘horrified’ because she knew this nurse had recently attended an
introductory educational session on traction and was undertaking studies in orthopaedic
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nursing. Ellen was concerned that the transition of knowledge to practice had not
occurred (E: 395-396).
Due to the lack of insight on the part of the nurse, Ellen called upon all her skills as an
educator, and diplomatically went about reapplying the traction. Ellen felt an
overwhelming ‘sense of obligation and responsibility as an educator to address the
situation …’ (E:194-195).
… there was a big problem with what was happening in nursing
practice there that I needed to address, or that I felt I needed to
address. (E: 311-314)
Ellen talked about being annoyed and angry that this patient wasn’t receiving the care
that he was entitled to, which reflected poorly on the hospital (E:286-291). She therefore
had no hesitation in rectifying a situation she felt ‘so strongly about’ (E: 274).
… I felt confident and comfortable to, to take those steps because
ultimately the patient is paramount … (E:278-279)
The incident was significant to this participant because traction is recognised as a basic
skill in orthopaedic nursing. ‘I suppose I see that traction as being a, a skill specific to
the orthopaedic nurse, traction application’ (E:377-378). Some orthopaedic nurses
would consider the application and care of the patient in traction, as one of those
orthopaedic nursing skills, fast becoming ‘a dying art’. This is why this incident remained
prominent in this nurse’s mind. That and the fact it was such a ‘blatant’ lack of patient
71
care. Ellen informed the CNC and the relevant nurse educator of the incident, and she
contributed towards the nurse’s performance appraisal.
I recall after the interview being equally impressed by Ellen’s strong sense of patient
focus, and commitment to supporting the nurse (fldnte:3). Indeed I was convinced
support and diplomacy were qualities that embodied Ellen’s nursing practice, evidenced
by her considered responses to my questions.
Interestingly three of the seven participants chose to relate a situation where the
application of traction was involved.
Ben
Ben chose an incident related to the application of traction also. He was called upon to
assist in the emergency admission to the ward of an elderly woman who had sustained a
traumatic intertrochanteric fractured left neck of femur (a fracture between two bony
landmarks of the upper femur).
The treatment ordered involved the application of a Thomas splint and traction.
Ordinarily the application of a Thomas splint occurs in an emergency department where
femoral nerve blocks, or an appropriate form of anaesthetic, can be administered so as to
minimise pain during the application of the leg long splint. Reducing a femoral fracture
can require a substantial amount of physical force and manipulation. Due to the large
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amounts of analgesia and anaesthetic required to facilitate the procedure, and to keep the
patient comfortable, close observation of the patient throughout and following the
procedure is required, which is usually not available at a ward level.
It was about 3 o’clock on a busy night shift in the unit and there had been several
admissions. Ben was relieving on another ward, but as the most senior qualified
orthopaedic nurse in the area he was called upon to assist with this admission. The ward
staff were relatively junior and unfamiliar with Thomas splint and traction. The patient
was a small and frail 86 year old woman who had sustained the fracture in a simple fall.
Ben described the injury as ‘a bit nasty’ (B:51), because the proximal fragment was
observed directly under the skin and could have easily pierced the skin and become a
compound wound. The patient was in significant pain because of the grossly unstable
fracture. At a glance, Ben observed the patient was frail and suffered from medical
problems. Her delicate condition concerned him greatly (B:213).
Ben spoke by phone to the orthopaedic medical registrar who had been delayed in
emergency operating theatre for some time. Ben requested his presence to implement the
treatment order. It was impossible for the medical registrar to attend. Ben was faced with
a dilemma between leaving the patient in severe pain with the risk of compounding her
injury and at risk of pressure sores, or intervening and applying the traction himself. Ben
discussed this further with a surgical intern and then surgical registrar. He struggled with
the decision as to whether he should clinically intervene or not. He had his doubts as to
whether the treatment ordered would succeed:
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So it was a bit of a tricky decision as to sort of just leave her and, she
would end up compounding or being in a lot of pain, being quite sore,
or trying to do something. (B:69-71)
Ben proceeded with a treatment he suspected wouldn’t work. Ben went about calmly
organising the equipment and overseeing the application of the splint; he noted ‘no-one
else knew how to set up the traction at all or what … that sort of stuff to do’ (B:116-117).
He monitored the patient’s condition throughout the one and a half hours it took to set up
the traction; he supervised the other Registered Nurse (RN), and reviewed the ward
situation from time to time, both this ward and the ward he was relieving on; ‘that was
another thing that I was thinking about, is making sure the patients were covered’
(B:443-444).
After some time it was clear to the medical team that the traditional form of traction
wouldn’t reduce the fracture, therefore Ben, by drawing on his knowledge of the
principles of traction and fracture management and previous experience (B: 277-278),
suggested an alternative way of reducing the fracture. This adapted form of Hamilton
Russell traction proved successful on this occasion.
Reflecting back on the situation Ben regretted proceeding under the circumstance, but he
felt he had no other choice.
I sort of have the twinge of, like I should have said no, or made
the ortho reg come up and see this lady or do something but, I
sort of know that that really wasn’t a possibility; or not for at
least a couple of hours if not longer. So I sort of feel, yeah I feel
good about it because it ended up in a positive way, we helped
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the lady, and we sort of worked as a team and everything went
okay. The outcome was positive …’ (B:560-565)
Ben was annoyed that standards of care had to suffer because of an organisational hitch,
however he understood the pressures placed on the institution (B: 613-617). Ben was
proud of the team effort and felt he’d ‘handled it pretty well’ (B:651). The next night he
followed up on the patient’s progress to make sure everything was alright.
I guess you see the results and you’re a part of that. I guess you know
that if you’d gone along a certain track and done nothing and left her
in a bad way or a negative way you’d think about it next time you’d
practice in this sort of situation. That’s all part of - I think experience,
is, about looking at the outcome in the end and seeing what you could
have done differently, or what you did well. (B:511-516)
When asked what Ben did well he replied:
Umm, [pause] I guess I didn’t panic. I drew on a lot of my experience.
Umm I think I assessed the situation as a whole. I thought I didn’t get
too focussed on one little thing. I made suggestions well and if I
thought they were umm important, sort of reinforced them … I was
assertive. (B:528-531)
The reason Ben volunteered this as an example of advanced practice was confirmed by
the praise for ‘handling the situation’ and respect of Ben’s abilities, the other RN working
with Ben, shared with him, afterwards.
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Anne
Anne shared a similar incident that involved the application of a Thomas splint and
traction in the ward situation. The elderly female patient involved had sustained a spiral
fracture to her femur between two prostheses, that is her total hip prosthesis and a total
knee replacement on the same leg, following a fall. In this example Anne was required to
oversee the application of the Thomas splint in the presence of the patient’s medical
consultant, junior medical registrar, nursing staff and of course the patient. It drew upon
many skills.
The junior registrar approached Anne and reported that the consultant had requested this
particular form of traction, but that the registrar didn’t know how to set it up and asked
her ‘what should we do?’ (A: 34). Anne explained the procedure to the registrar, but was
also mindful that her nursing staff were going to have to care for this patient. Anne
organised for the relevant information to be made available, because she did not want the
patient to detect a deficit in the knowledge base of the registrar or nursing staff (A: 47-
49). Meanwhile Anne discussed the treatment plan with the consultant over the phone.
She described the patient’s condition and informed the consultant that she wasn’t happy
to apply the splint and traction until x-rays were available and he was present (A:141-
149). Whilst waiting for the consultant to arrive Anne kept the nursing staff allocated to
the patient informed of what was going to happen. Anne reviewed the staffing needs for
the next twenty four hours, confident in her nurses’ ability to care for the patient.
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When the consultant arrived, the team discussed how they planned to proceed. They then
entered the patient’s room. During the three and a half hour procedure Anne assisted the
consultant, observed the patient and supervised the RN. Anne felt it was necessary to
diplomatically ask the consultant why he chose to do things in a certain way at times, in
order to clarify where his thoughts were heading. Anne was concerned about the amount
of intravenous analgesia the patient may require and had previously suggested the
registrar consult with the appropriate medical officer, which he did. The procedure was
successful.
Reflecting back on her role as a nurse in this situation Anne perceived:
I would probably say I was an advocate for the consultant and
registrar and the registered nurse. Probably acting as a leader just
directing and making sure that everything was going smoothly, keeping
everyone calm and relaxed. Being professional at all times.
(A:252-255)
During the interview Anne stressed the importance of staff education and felt it was
important that staff did not appear uncertain in front of the patient. She also emphasised
to me the time she spent educating the patient. Throughout the following six weeks the
traction was in place, Anne began to take less of a ‘hands on’ role with the patient, as she
observed her staff demonstrating greater competence and confidence in looking after this
patient.
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When recalling this experience during the interview, Anne appeared confident and sure
of herself. She approached the recounting in a concise, methodical and professional
manner as reflected in the following words:
As a professional with knowledge, experience in that area. Feeling
confident in my interactions with the patient, with my interactions with
the other staff, with the consultant and the registrar. I see myself as
more of a coordinator; I don’t like really to say I am a leader, but more
of a coordinator. Just making sure that everything’s smooth and runs
according to plan. I don’t like stress, and I don’t like hassle and I don’t
like people being - “I don’t know what I’m doing” - feeling not
confident.
Anita: Do you think you achieved this?
Mmm, I think so. (A: 345-352)
Carol
Described a complex ward management issue surrounding the direct admission to the
ward of a young man involved in a sporting accident who had sustained a lower limb
fracture. This nurse felt strongly about addressing, what she believed was a situation that
could potentially compromise this patient’s care due to the absence of medical
assessment and stabilisation of the injury prior to admission to the ward. Moreover she
wanted to prevent this occurrence from happening again.
The young man arrived on the ward screaming in pain. He had been classified as an
‘arranged admission’ because his General Practitioner (GP) had spoken directly to the
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orthopaedic registrar, however briefly, and therefore the patient was ‘expected’. He
bypassed the emergency department and was sent directly to the ward.
… often [it] is very complicated because the paperwork doesn’t come
with the patient; because they haven’t really been admitted; they
haven’t gone through admissions and more importantly they haven’t
been seen by medical staff and stabilised in casualty. And so they are
sent up, often in quite a lot of pain, often all their injuries aren’t fully
assessed and there may be another injury that we are not aware of at
the time when they arrive on the ward … (C:99-104)
Carol welcomed the patient to the ward, quickly found a bed for this patient (by
diplomatically asking a patient awaiting discharge to vacate his bed), attempted to calm
the patient because he was screaming in pain, placate the parent’s anger and arranged an
intern to assess the patient. Carol’s main concern was the risk that this patient may have
sustained a spinal column fracture that had not yet been detected (C:135-137). Carol felt
confident he hadn’t, because of the degree of trunk control the patient displayed. It was
important to Carol that she maintain composure despite feeling ‘angry and furious’ that
this type of admission had occurred again (C:166).
Carol’s next task was to get this patient settled into a bed, calm him down, and make him
comfortable. She was aware that the patient and his parents may have lost confidence in
the hospital system as the admission seemed to be disorganised. Carol delegated the
admission of the patient to the ward to an experienced Enrolled Nurse (EN).
Fortunately the consultant arrived on the ward just as she was thinking about contacting
him, as Carol had not been successful in contacting any other doctors and she knew the
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patient needed to be urgently assessed. Carol appraised him of the situation, and
reminded him that she had previously raised the issue of medically unassessed patient
admissions direct to the ward, with medical staff only the week before. The consultant
organised for an orthopaedic registrar to review the patient. Meanwhile Carol was already
preparing to administer pain relief once it was ordered. The patient attended x-ray, was
fasted for the operating theatre and settled into the ward.
And in the midst of all that, once I got that under control, as much
control as you can, the following up issue dealing with …and going
and talking to [the relevant] CNC about the issue. (C:121-123)
Once the ward had settled down, and Carol made sure all staff had been to lunch, and the
afternoon shift staff had arrived, Carol attempted to resolve the issue of unsafe patient
admissions to her ward, with the relevant member of the nursing staff. ‘And as much as I
had tried to use all my conflict resolution skills, nothing was resolved’ (C:126-127).
Carol felt frustrated and disappointed that an opportunity for nurse ‘colleagues to
problem solve and overcome things’ had been lost (C: 720-721; 506-507). The matter
encroached upon broader political issues within the hospital and therefore was dealt with
by the appropriate personnel, from the relevant disciplines. However Carol felt her efforts
had been thwarted because ‘the frustrating thing for me in all of this is the patient was
being disadvantaged’ (C: 550-551). Her last thought when leaving work that day was for
the patient and hoping there wouldn’t be a delay in his going to operating theatre:
… his admission had been, you know a stuff up more or less. (That) his
admission hadn’t run smoothly. It didn’t look good for the hospital; it
didn’t look good for the ward (C: 525-527)
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Later on down the track, Carol informed the patient of the patient advisor role (patient
sopprt service), and explained to the patient’s parents what should have happened during
the admission process because she felt ‘they have a right to know’ (C: 713). Carol
discussed the conflict this occasionally presents:
You’re in a really precarious position, because yes you can be a patient
advocate to a point, which I really believe should be. But at the same
time I am an employee of the hospital and you can’t umm, you can’t
[pause] … put the hospital down… (C:713-717)
Carol maintained a composed, professional demeanor at all times, particularly throughout
her contact with the patient, his family, medical and nursing staff. She demonstrated a
concern to protect the reputation of the ward and hospital, and promote the nursing
profession.
Upon reflection Carol stated ‘I don’t think advanced practice is just clinical skills’
(C:733). She believed it’s about how an institution works, policy development, conflict
resolution and delegation, which was the focus of her story (fldnte:10).
Fay
By far the longest interview, Fay described a complex ward situation like Carol, which
involved the transfer of a young male victim of a fork lift accident from a Queensland
hospital. This patient had sustained multiple bilateral leg fractures and presented with a
large necrotic pressure sore to one heel.
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Not only were there the complicated logistics of patient transfer, and negotiating a
treatment plan for this patient at a time of bed closures and winding down of hospital
wide services, there was also the issue of a complex family dynamic. This nurse had a
dramatic impact on the coordination of this patient’s care and the direction the hospital
admission took, over a relatively short period of time. Her suggestions considered every
aspect of holistic care.
Fay arrived on duty one morning to find the young male patient had arrived unexpectedly
during the night. Fay had alerted the casualty department and the other orthopaedic wards
to this possible transfer (F:335-337). She thought there was a chance this patient would
arrive unannounced, after being disappointed with the lack of information the nurse at the
Queensland hospital was willing to impart to Fay about this patient; ‘I got the feeling she
wasn’t telling me everything’ (F: 362-363). Fay read his notes and ‘… started having a bit
of a chat with him before the ward round’ (F: 374-375). Fay discovered the patient ‘had
had enough’ and ‘got the impression it was important to keep them [the family] fully
informed’ (F:387). So before the doctors left the ward, Fay insisted they inform him of
the treatment plan (F:132-134).
The team established he was non-weight bearing (NWB) on both legs due to an unreimed
(unsecured) nail inserted into the femur. Fay suggested they replace the non-weight
bearing nail with a weight bearing nail ‘…’cos I’d seen it before’ (F:314). Her suggestion
was well received and relayed to the consultants (F:487). When the orthopaedic team
were reviewing the patient’s ankle Fay suggested perhaps the patient should be referred
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to the orthopeadic foot specialist. The medical team responded favourably to this
suggestion. Although the heel wound did not concern the doctors, Fay was most
concerned: ‘…looking at it I can assure you that it wasn’t going to [heal]…’ (F: 125).
I just felt that, that was important to get them [plastic surgeons]
involved. It was a huge necrotic area, really sloughy, and that was… I
looked at it and it just reminded me so much of this other case of ten
years ago; that required skin grafting with muscle flaps. Didn’t want to
go on and just dressing it for weeks on end, and we were about to send
him home, to then decide they wanted to do grafting and muscle flaps
on it. May as well get it all done now in the acute phase. ‘Cos I also
suggested to them, you know if you’re going to get plastics involved
and they want to do some grafting or anything, if they were considering
doing the nail, then they did it all at the same time with one anaesthetic
(F:704-713)
Fay was very much aware that the patient didn’t want any further surgery (F:402).
Fay considered the input from other members of the multi-disciplinary team, that could
possibly assist this patient’s healing and recovery. She therefore notified the dietician and
explained to the patient, who was of slight build, the benefits involved of a good
nutritional state (F:440-447). Fay also arranged for orthotics to modify his splint (F:470).
When asked, Fay said she felt ‘empowered’ by making suggestions and having them
taken seriously (F:491). She made a point of educating and involving the patient in the
decisions about his care, which she would do for any patient, but more so in this case
based on her impression formed after her initial assessment.
… “no-one’s ever spoken to me about any of these sort of things
before”. I think it was a whole new experience for him. I mean I must
admit I don’t know whether he took in everything I said. Umm, but I
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think he seemed happy that we actually were providing him with some
information and I just left him with “if you’ve got any questions, or you
want to know what’s going on, just ask, you know we’re not going to
bite your head off. I’m not going to profess I know all the answers”. I
said “we can certainly try and find the answers”. He seemed to be
happy with that. (F:551-558)
Fay kept the nursing staff caring for the patient informed, and began to take less of a
direct role in his care, as she concentrated on managing the ward. The patient was handed
over in detail to the CNC covering the Christmas period, at which she emphasised her
‘main concern to everyone was the heel wound’ (F:690).
An issue Fay felt strongly about following up was the communication issue with the CNC
in Queensland, and after consulting her colleagues she did take some action and reported
the incident to this CNC’s line manager. ‘I felt very strongly about it at this point in time
because I just felt all I was trying to do was be an advocate for the patient and try umm,
look out for his best interests’ (F:223-225) and maintain continuity of care.
At the end of the day, when asked to reflect upon her actions, Fay felt ‘she hadn’t done
enough for the patient’ (F:960). But she felt ‘good’ that her suggestions were taken up
and she was able to ‘initiate’ holistic care for this patient (F: 939).
My impression of Fay as she reflected several times upon her actions, that she seemed to
take her professional growth very seriously. Her answers to my questions were
comprehensive but considered.
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Emergence of Preliminary Concepts
Di’s story described an extraordinary event but at the same time highlighted skills that
she would use in her everyday practice. She had specific knowledge of the patient’s
diagnosis and the implications for nursing care this knowledge afforded. However, Di
intuitively knew, having not received handover, at what point in the post-operative
recovery the patient had reached because she knew ‘she must have been day two because
she was able to walk’ (D: 121). Upon confronting the emergency situation Di
incorporated her orthopaedic knowledge into her assessment of the patient. Using her
superior assessment skills, she quickly identified the need to maintain the patient’s
airway whilst supporting the spinal fusion.
Di used her underlying knowledge to support and educate the junior staff. After
checking on the patient in the toilet, Di had mentioned the importance of bowel care to
both patient and staff. Di was aware of the manner in which junior staff reacted to the
cardiopulmonary arrest situation. It was important to her that the enrolled and student
nurses were debriefed as soon as the situation allowed. Di reassured the other RN that
she would ‘go through what happens in the event of an arrest’ with the EN (D:345).
Di demonstrated knowledge of a different sort in her assessment of the entire situation. In
the middle of the emergency Di took control and directed staff to perform certain tasks.
Di knew the background of each staff member, which therefore enabled her to delegate
appropriately. She had prioritised this patient’s care above other patients on the ward as
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needing her care and remained with the patient whilst the situation warranted it. At the
appropriate time, Di withdrew from the patient’s direct care to re-assess the ward
situation. Di’s management of a complex situation involved analysing the ability of all
staff members, including medical staff. This presented Di with a conflict when she found
herself questioning the competence of the medical intern. As a result Di felt the need to
go outside of her role as the nurse and control what emergency care was given. Di felt
she had engaged in good nursing and felt rewarded when the patient expressed her
gratitude on discharge, which made Di think ‘that’s what I’m here for’.
Reward for Gina came in her ability to draw on all her education and knowledge, ‘not
just specific orthopaedic knowledge but that higher level of orthopaedic knowledge’ (G:
585-586). Gina used this knowledge to make decisions about her patient’s care.
Furthermore Gina was professionally stimulated by her ability to interact with medical
staff at a higher level. The patient Gina saw in clinic that day, reported symptoms of the
type which alerted Gina to the patient’s need for further assessment. Gina passed this
information on to the appropriate medical staff. In her assessment of the patient Gina
exercised professional judgement. She identified a medical problem that had the
potential to impact on the decision as to the timing of surgery. She was confident she
could predict how long it would take this patient to recover from her surgery, therefore
impacting on their length of stay.
The other concept that began to emerge from Gina’s story was the issue of her role. Gina
talked about her role in general terms but also the association her role had in relation to
86
other medical personnel. This relationship needed to work well for the smooth running of
the arthroplasty clinic. At times Gina felt she had to take on the role of the registrar, and
this left her with mixed feelings. Notwithstanding, Gina welcomed the responsibility the
role carried.
Ellen also took on the responsibility of patient advocate and educator without question.
She was motivated by an overwhelming concern about the standard of patient care and
the implications for nursing practice. Ellen could sense the patient’s discomfort and
having assessed the ward’s activity Ellen decided to approach the situation as a learning
opportunity for the nurse concerned. Ellen was familiar with this nurse’s background, so
she was prepared to draw on her skills as an educator and rectify the situation. Ellen
referred to the ‘inner conflict’ associated with balancing competing demands of her role
(E:317-22). Like the other participants, Ellen talked about a strength of feeling which
compelled her to act and of feeling good once a positive outcome for the patient was
achieved.
Ben felt conflicted from the start of his incident, but had an understanding of the
organisational demands that were impacting upon his ability to make a decision about
this patient’s care. He was confident in the knowledge he had gathered from previous
experience and undertaking education, that he could manage the situation, but
concerned and annoyed that the patient was in this predicament (B: 251-253). Ben
coordinated the team through the application of the Thomas splint. He knew the
background of the members of the team and was pleased with the overall team effort
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but felt fortunate the outcome was positive. Ben organised all the equipment and
anticipated some needs. Ben demonstrated an ability to critically analyse and reflect
upon the situation, as evidenced by the misgivings he still harbours.
Anne shared an experience that involved the application of Thomas splint and traction as
well. She approached this situation in a calm and organised manner and considered the
full impact nursing a patient in a Thomas splint would present. Anne had anticipated
what was required for the procedure, prior to the consultant arriving (fldnte:14). After
ensuring the application of the splint went smoothly, much of Anne’s effort was spent in
educating the patient and her staff, in order that the care the patient received was of the
highest standard. Anne remained a strong patient advocate throughout. She endeavoured
to project as a competent professional, certain of her convictions (A:154) and
philosophy of care.
Professionalism was a concept that emerged strongly from Carol’s story. When the
patient arrived on the ward, she welcomed him warmly and didn’t allude to the
extraordinary circumstances surrounding his admission. As a priority she efficiently
attended to his clinical needs. She delegated his care to a nurse she knew would deal
with the situation appropriately.
Confident that the ward was under control, Carol attempted to discuss the inappropriate
admission with the relevant nursing personnel in the hope of resolving the matter. It
disappointed Carol that she wasn’t able to advance the cause of nursing in this instance.
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She was however, resigned to the hierarchical politics that exists in a large institution that
had an impact on this circumstance. She demonstrated professionalism in her relations
with patients and colleagues (C: 622-623) and professional maturity in reflecting
personally on how to act in situations such as this (C:634-639). Carol demonstrated a
breadth and complexity of her role as she described her performance at a ward level and
then at an organisational level. She mentioned the tension in her role between patient
advocate and the need for diplomacy, versus her role as an employee which implied a
need to juggle or balance competing demands, a concept alluded to by some of the other
participants.
Finally, Fay described a complex situation that required the sensitive handling of a
situation outside the ward environment. Fay drew on her assessment ability and
orthopaedic knowledge to firstly sum up the situation, then suggest and determine
priorities for care. Fay conveyed to the team her impression of the patient’s physical and
emotional condition. She felt strongly about acting as a patient advocate and went to
every effort to involve the patient in his care and explain the possible treatment plan. She
showed evidence of reflection on her performance and anticipated she would ‘grow’ as a
result of this incident (F:903). Fay referred to previous exemplars in her practice that
affected the way she delivered holistic care.
Preliminary concepts began to emerge from the participant’s descriptions as words or
phrases that occurred and reoccurred throughout repeated reading and listening of the
text. It was not clear the significance these words might have in the interpretive process.
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In summarising the stories of these nurses I have highlighted words or phrases that may
prove to be of significance during thematic analysis.
Conclusion
This chapter has summarised the participant interviews and presented preliminary
concepts that began to emerge from the descriptions that were verified as accurate by all
but one participant who had moved interstate.
I have attempted to preserve the uniqueness of the text in this chapter by directly quoting
from the nurses’ narratives. The incidents the nurses described focused on the individual
actions and interactions with others in a particular situation. The nurse’s choice of
incident revealed much of how they wished to be seen as a nurse and an advanced
orthopaedic practitioner (Fagermoen, 1997:437). Their self representations formed the
basis of the interpretation that was to follow.
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Chapter 6
An Interpretation
Introduction
This chapter will thematically deconstruct the participant descriptions summarised in the
previous chapter. A feature of the phenomenological method is to ‘get at’ the narrative or
‘dwell with the data (Fitzgerald, 1998). This is the aim of textual analysis. A
contemplation of the data will uncover the meaning of the lived experience of advanced
orthopaedic practice. Hence the researcher listened, read and re-read the texts. Thoughts,
concepts and patterns of meaning emerged as I familiarised myself with the data.
Eventually the meanings behind the phenomenon revealed themselves and themes were
developed. Themes were evidenced by examples from the data. In hermeneutics the role
of the researcher is to thoroughly understand the text by constant reference from the parts
(each participant) to the whole (emerging concepts and themes). Therefore, I would ask
myself, What does the word ‘knowledge’ mean for this nurse as an advanced orthopaedic
practitioner? To link an emerging concept with the theme I would ask, How does
knowledge relate to the experience of being an advanced orthopaedic nurse? Finally I
referred to theoretical frameworks and extant nursing literature in the field to expand
upon the themes. Interpretation is completed when creating the phenomenological text,
that is the writing up of the study report. Analysis occurred using the principles of
hermeneutics as described by van Manen (1990).
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Interpretation requires the researcher to establish a dialogue with the text. This was
achieved by asking questions of the text, What does this word or phrase mean in the
context of this part of the story? or, What does this passage reveal about the whole
experience being described? The text began to ask questions of myself such as, What do I
understand these feelings to mean? By constant questioning and movement between the
different perspectives of the hermeneutic circle, emerging concepts developed into the
following themes: having knowledge; being in the role and outside the role; being an
advocate and being in control. Themes will be exemplified by reference to
representations from within the text.
Having knowledge
Knowledge and its relationship to nursing practice has been the subject of much
discussion within the nursing literature. Similarly, the theme having knowledge was
strong amongst the participants, maintaining a pervasive presence in each story. Di’s
specific orthopaedic knowledge had an immense impact on the outcome for her patient,
because it underpinned her every action. She reflected:
… if we hadn’t been lateral thinkers with her orthopaedic knowledge…
we could have done more damage than good. (D:415-417)
This was contrasted by the lack of knowledge of junior nursing staff, which was of
concern to Di:
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… possibly they don’t have a lot of spinal knowledge, about
maintaining alignment and that’s not their fault but inexperience and if
you haven’t been given the opportunity to experience nursing spinal
injury patients, or nursing just patients post spinal surgery, which we
don’t get a lot of, you know they just haven’t got that experience.
(D:263-268)
This example demonstrates the knowledge gained from experience, and as Sutton and
Smith posit ‘…the knowledge derived from experience is a particular type of knowing …
the knowing how’ (Sutton & Smith, 1995a:138 and Jasper, 1994:771), which contributes
to expert knowledge. Gina differentiates between the ‘knowing that’ and the ‘knowing
how’ (Kuhn 1970 and Polyani 1958 cited by Benner, 1984:2). She refers to ‘specific
orthopaedic knowledge’ and ‘that higher level of orthopaedic knowledge’ (G: 585-590),
which supports the notion of a higher level of nursing practice (Humphries, 1998:10-13
& Maclaine, 1998:159-630). She explained the assessment on range of movement and
joint function that she performs is more advanced than the assessment an ordinary ward
nurse would perform, if at all. This infers it is one thing to perform an assessment but
another to know what the outcome of the assessment means and then be able to apply it
to practice. Gina would assesses the patient’s pre-operative status, and use this
information to exercise clinical judgement in determining discharge needs. For example,
the patient described her nocturnal chest pain. Gina recalls:
… just thinking back to university about angina symptoms and things
umm, made me think that it could be something along those lines
because I can remember specifically with chest pain at night was
related to angina … Yeah it’s amazing how quickly you whip through
with it in university, you think you’re never going to retain all of this
information. It’s amazing, when you see it in practice how often you put
two-and-two together, and it just clicks in your mind and yes I
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remember this and that and other things you are supposed to be
looking out for, and it all came back to me. (G:73-83)
The transition of knowledge to practice features in Ellen’s story. The lack of knowledge
the nurse possesses is juxtaposed against Ellen’s educational role.
[The nurse caring for the patient had attended] … an introduction to
traction [education session] and we had demonstrated Hamilton
Russell traction, which was the traction application here. And that
umm, they were involved in an orthopaedic nursing course and had
covered lectures on traction as well, so there was more umm, times that
education had been given to that person in traction application and
some practical sessions within those as well. That the actual personal
umm - transferring of, or transition of knowledge to practice just
wasn’t happening. (E:390-396)
This example suggests knowledge is more than formal education alone. The example also
emphasises that nursing is both an art and a science. Praxis is the combination of practical
and theoretical knowledge (Sutton and Smith, 1995a:144); a concept embodied in
Benner’s claim that knowledge is embedded in practice (1984:2-3), however there needs
to be a dialectic between the two forms of knowledge.
Ben drew on his ‘knowledge and skills’ (B:141), a previous experience (exemplar) and
education (B:277-278), in order to feel confident managing the application of the Thomas
splint and traction on the ward, despite his misgivings. Ben also drew on his knowledge
of similar experiences:
… I mean the nuts and bolts of what happened is different to what I
have ever been through before but it’s a situation that has the same
sort of stressors, the same sort of concerns and the same way of
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approaching it I’ve done quite a few times so I guess yeah … yeah I
probably learned a bit. (B:549-552)
Not only does this example typify the complexity and breadth of knowledge required for
expert/advanced nursing practice, it does show evidence of reflection, another aspect of
nursing knowledge which aids knowledge development. Ben reviewed his patient’s
progress on his next shift:
… to make sure everything was alright. I guess you see the results and
you’re a part of that. I guess you know that if you’d gone along in a
certain track and done nothing and left [the patient] in a bad way or a
negative way you’d think about it next time you’d practice in this sort
of situation. That’s all part of I think experience, is about looking at the
outcome in the end and seeing what you could have done differently, or
what you did well. (B:511-516)
Reflective practice is an important notion in the achievement of advanced practice.
Sutton and Smith (1995a:144) state ‘… critical reflection on practice and integration of
the outcomes with what they [advanced nurse practitioners] know in order to further
develop, [where] the unification of theory and practice provide[s] … distinctive ways of
thinking about practice. Gina talks about ‘trusting my own judgement a bit more’
(G:477). Ben reflects:
… you’d think about it next time you’d practise in this sort of situation.
That’s all part of I think experience, is, looking at the outcome in the
end and seeing what you could have done differently, or what you did
well. (B:513-516)
Anne also recognised the value of her ‘knowledge and background experience of how to
assist with the setting up of traction’ (A:71-72). Benner states it is ‘… an enormous
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background of experience…’, which distinguishes expert performance (1984:31-32).
Fay’s experience, education and knowledge enabled her to make suggestions about her
patient’s care. She also drew on exemplars to inform her practice, to justify her
suggestions and nursing interventions. Fay’s suggestion to ‘change the nail over so at
least he had a weight bearing leg’ (F:315-316) emanated from a previous incident.
Similarly her concern over the heel wound reminded her of a case she had seen ten years
ago (F: 706). The use of clinical exemplars was pioneered by Benner and is well
established within interpretive nursing research (Harvey & Tveit, 1994:45-53).
Benner (1984:37) refers to ‘multi-facetted knowledge with referents’. Sutton and Smith
contend the nature of knowledge is complex and multi-facetted (Sutton & Smith,
1995a:138). They suggest advanced practitioners subsume intuition within their
perception of the totality of the situation (Sutton & Smith, 1995a:145). The best example
of this from amongst the participants is Carol. Carol recognised the complexity of the
situation before her when the patient arrived unexpectedly on the ward. She welcomed
him to the ward, found him a bed when there previously had been none, assessed that the
patient did not appear to have a spinal column fracture, and allocated a staff member to
his care. She organised for a medical officer to assess him as a priority, and knew she
must follow the issue up with the relevant staff, as a matter of urgency because she was
acutely aware of the risks of having a patient arrive to the ward not assessed by a doctor.
Carol did not want this scenario to be repeated. She therefore followed the issue up with
the relevant members of the nursing and medical staff.
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Fay also demonstrated an ability to hone in on the more salient aspects of her situation,
then work through her priorities one-by-one. Upon realising the patient was on the ward,
Fay made a point of reading his notes then having a ‘chat’ with him (F: 369-375). Fay
used the information gained from this assessment to determine the patient’s priorities of
care. Her language made evident the perception, impressions and intuition that existed in
her practice. This was highlighted in some of her phrases ‘… I got the impression that
information was very important …’ (F:387); ‘… I really sensed all this…’ (F:394) and ‘…
I just felt that…’ (F:704). Fay was clear about how the orthopaedic team should manage
the care of this patient. Fay was also aware of the constraints operating within the
hospital at the time of ward closure and Christmas holidays, and she therefore liaised
with the appropriate personnel in a timely manner.
All of the other participants demonstrated an ability to intuitively assess a situation. Di ‘s
actions were second nature as is important in emergency situations. Gina assessed her
patient in a precise manner:
… even when she just came around the corner toward my office I
thought “ ooh, she’s not real mobile”. (G:234-235)
Ellen performed ‘a quick overview’ of the ward situation and determined this patient was
a priority (E: 187-188). Ben ‘s first impression of his patient was that:
… she was a frail old lady who was quite small and she was quite with
it. But she’d obviously had medical problems you could tell that by
looking at her. And umm, you could see her hip…And I also noticed
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that her upper leg was deformed, it wasn’t natural alignment. Umm,
and I noticed that she was in pain… (B:188-203)
Whilst he may not have predicted the outcome, he knew intervention was warranted.
Anne knew she had to remain calm and in control of the situation with the patient, her
nursing staff, the registrar and consultant in her story (A:252-255). The ability to ignore
extraneous information and ‘zero in on the accurate region of the problem’ is
synonymous with expert practice and subsequently draws on expert knowledge (Benner,
1984:32). Therefore having knowledge, in whatever form is integral to the concept of
advanced practice, as the participants demonstrated to some extent or another.
Being in the role and outside the role
The theme of being in the role and outside the role emerged from each description,
however the concept differed according to the participant’s context. The role of the
registered nurse is regulated by legislation, organisational policies, procedures and
protocols, which are designed to elimninate confusion over role boundaries. The
traditional role of the nurse however, has displayed deference to the medical profession.
Di felt frustrated and guilty about the medical intern’s seeming incompetence. She was
frustrated that his priority of care during the emergency did not accord with hers:
And I just said it’s [a postural blood pressure] totally inappropriate. It’s
just not warranted and if you’re not competent enough to assess this
patient I’ll get someone else to do it. (D:195-197)
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She felt ‘a bit guilty’ (D: 3550 about telling him what to do but she took control of the
situation regardless. She felt compelled to go outside the role of the nurse however. It
was not until Di reflected on the situation that she acknowledged her feelings:
And I thought I’ll let, I’ll just let it go because it’s a lesson learnt that
sometimes you can’t trust the medical staff. As much as they’re medical
staff they’re novices in their own profession, they’re only beginners.
(D:361-363)
Gina mentioned the interface her role had with the orthopaedic registrar. She expressed
‘mixed emotions’ and ‘frustration’ about taking on the role of the registrar, that is in
terms of ‘extra responsibilities’ and tasks. But she certainly enjoyed the responsibility
and high level of interaction with the muti-disciplinary team (G:126 & G:591-592). Ben
also knew he was challenging role boundaries when they applied the Thomas splint, in
the absence of an orthopaedic registrar.
I felt confident in a way, I mean I knew we were doing stuff that, we
weren’t really [slight pause] qualified or whatever – for want of a
better word, to do but I knew sort of, I had the knowledge and skills so
hopefully we could fix it in the end… (B:139-142)
Ben was uncomfortable about his being outside the role, but he was able to reconcile this
and determine a course of action for the patient. Di, Gina and Ben experience some
discomfort being outside the traditional role of the nurse, which is in contrast to Ellen,
Anne, Fay and Carol.
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Ellen experiences ‘inner conflict’ when attempting to reconcile competing demands on
her role (E:322). When she encountered the situation of inappropriate traction application
however, she had no qualms about acting. ‘I felt a strong sense of obligation and
responsibility … to address the situation’ (E:194-195). Ellen acknowledged she had
stepped out of the role but felt ‘confident and comfortable to, to take those steps because
ultimately the patient is paramount’ (E:278-279).
In her story Anne is confronted with an orthopaedic registrar who, because of a lack of
knowledge, is unable to implement the treatment recommended by the consultant. Anne
assumed the defacto role of registrar and assisted the consultant in the application of the
Thomas splint and traction. In contrast to Ben she feels entirely confident being outside
the role:
I was confident in what I was doing. I felt happy that he [the
consultant] felt confident in me to assist him (A: 320-321)
Whilst Fay did not go outside the role, the suggestions she made to the doctors would not
be typically made by the ordinary nurse, and yet were quite consistent with her role as a
nurse. She felt empowered being able to make suggestions about patient care:
… you can make suggestions without being - oh them biting back and
saying it’s none of your business. Umm, I think too it’s all to do with
your own confidence and where you are within nursing and within
yourself… I suppose in this role you have to do … if you don’t say
anything nothing ever happens… (F: 491-496)
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Fay’s sense of professional pride was shared with Carol. Carol refers to a desire to
‘maintain my composure’ despite feelings to the contrary, when the patient first arrived
on the ward, and when she discussed the admission with the other nurse (C:171 &
C:453). Carol believed the consultants had ‘respect for me and my practice’ (C:603) and
talked about ‘maintain[ing] a professional front with my colleagues’ (C:622-623). There
was a strong sense of self and professional maturity that emerged from Carol’s story,
evidenced by her commitment to her principles (C:498-499) and a desire to promote the
interests of nursing (C: 503-511). Sutton and Smith (1995a:144) suggest advanced nurse
practitioners see the ‘potential future situations’ and ‘stretch the boundaries of nursing
practice’.
My impression of Ellen, Anne and Carol is a strong sense of professionalism. Perhaps
this is because they were comfortable being in the role and outside the role of the
Registered Nurse.
Emerging from the participant’s descriptions was a sense of the complexity of being in
the [advanced practice] role. In addition to clinical skills, these nurses were expected to
be an organiser, overseer, initiator, co-ordinator, manager and consultant, to name but a
few of the different aspects of their roles, as evidenced in the narrative text. Professional
stimulation and satisfaction was important to them. Perhaps the concept of advanced
practice remains elusive because of the challenge to accommodate all of these needs and
the ever-changing health care environment. However, my impression of each participant
is that they felt strongly (in both a positive and negative sense) about being in the role
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and outside the role, and were primarily motivated by doing what’s best for the patient.
Sutton and Smith (1995a:143) suggest when the patient is considered central to care,
advanced practitioners are ‘willing to bend the rules’.
Being an advocate
The theme of being an advocate is pivotal to the role of the advanced nurse practitioner.
Commonality across the participants was clearly evident. The sense of patient advocacy
tended to be communicated by the words ‘my concern’. Di was concerned that the patient
had been left in the toilet for too long. She was concerned that bowel care had not been
attended to, and she was concerned about maintaining the patient’s dignity:
I was speaking to her daughters and they pointed out that she’d been in
the toilet for fifteen minutes and they wanted to see if she was alright.
And instead of them walking up [to] their Mum attending to her
activities of daily living, I thought, maintaining her privacy and respect
I’ll just go in there… (D:125-128)
Ellen’s primary concern was for the patient.
I was concerned to see that this person [patient] had been – obviously
for some period of time – with their traction apparatus not being
applied correctly … [and] something needed to be done about it
straight away. (E:73-77)
She was ‘concerned about the standard of care that wasn’t happening for that patient’
(E:100-101). Her strong feelings of annoyance and anger related to the patient not
receiving the care he deserved.
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I was annoyed. Umm, that here was a patient who was in someone’s
care and they weren’t receiving the care that they were entitled to … I
suppose some of that annoyance was also anger as well. And it reflects
not only … the person that’s missing out on the care, … it reflects on
nursing care that’s being provided, really by the hospital. (E:286-291)
Ellen was being an advocate for the patient, the nurse and the hospital:
I felt good about - like what had happened - in that things had been
picked up for the patient. Some things had been addressed with the
nurse in the situation. (E: 347-349)
Ben was strongly motivated by the best interests of the patient, but protecting his
patient’s interests presented him with a dilemma. There were obvious risks applying the
Thomas splint on the ward ‘with not a lot of support’ (B:65), but equally there were the
risks to the patient if nothing was done. Ben was ‘concerned’ about the patient’s frail
condition (B:188-190). Ben decided to proceed, because of his desire to assist the patient.
Ben was frustrated that the patient was in this predicament, and that ‘standards [of
patient care] went down a bit…’ (B:616-617).
Anne was a strong advocate in her story:
I would probably say I was an advocate for the patient, an advocate for
the consultant and [orthopaedic] registrar and the registered nurse
(A:252-253)
Being an advocate manifested consistently throughout Anne’s story.
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We kept the patient reassured all the time. We explained that it was a
very delicate procedure; we were waiting for x-rays, waiting for the
consultant and also making sure that the knowledge base of either the
registrar or the junior staff was such that they weren’t able to care for
here once it was in place. (A:45-49)
Throughout the procedure Anne’s abiding concern was for the patient:
You have just got to be very careful in front of the patient as to make
sure they are completely at ease. That you really know what you are
doing … (A:56-57)
[and]
I was feeling strongly for the patient to make sure that her pain was
controlled. (A:52-53)
Had the procedure been too uncomfortable for the patient Anne was prepared to stop the
procedure and ensure the patient received the appropriate analgesia (A:243-246). Anne’s
abiding concern motivated her to educate the nursing staff and ensure adequate staffing
levels so that care was provided for this patient.
Carol too shared an abiding concern for the welfare of her patient and prospective
patients. She was ‘frustrated’ that the patient was being ‘disadvantaged’ over an
organisational conflict (C:550-551). Her concern for the patient motivated her to speak
with the relevant Clinical Nurse Consultant, her Nursing Director and the orthopaedic
consultants. She also advised the patient of his right to access the patient advocate (the
hospital’s patient support service), and informed the patient’s parents that there had been
an irregularity with their son’s admission to the ward.
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Fay’s overriding concern for the patient was to determine his treatment plan and involve
him in his care. She was concerned from the outset with the lack of information
forthcoming from the Queensland hospital. ‘I felt I was doing the right thing for the
patient, for continuity of care’ (F:837-838). Fay had assessed how important information
was to this patient so she went to every effort to involve him in his care, and start to
generate some positive outcomes for this patient. Advocacy as an expression of caring is
considered to be a function of expert nurses (Copp cited by Adams et al, 1997:219).
Furthermore advocacy is highly regarded by expert nurses and is an extension of a
nurse’s self esteem and professional identity (Adams et al, 1997:220). Sutton and Smith
(1995a:143) describe advanced practitioners as being patient-focussed, that is ‘the client
is the centre of that world [of practice]’.
Being an advocate also manifested itself in achievement of patient outcomes of care. Di
believed they had provided ‘good nursing’, Di didn’t feel rewarded until the patient was
discharged.
… the patient thanked us and kissed our hand as well and was so
grateful, and that was a rewarding feeling like, a positive feeling and it
made you think that’s what I’m here for, that feeling (D:371-374)
When discussing how ‘fantastic’ she felt the next day, a nursing colleague of Di’s said
‘that’s what it’s all about’ (D:428). This notion was identified in some of the other
narratives. Gina had received positive feedback from some of her patients:
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It’s really nice feedback to get that. Like I had two yesterday out of four
patients I saw. One was coming back for a revision of his hip
[prosthesis] and this lady was coming for the second knee
[replacement] and who said exactly the same thing. They found it was a
lot more beneficial to have the pre-admission education the first time
round … It makes you feel good, and it makes you feel that there must
be something good in the system at the moment (G:415-424)
Ben received ‘profuse thanks’ from the patient (B: 505) and he felt ‘good’ because the
outcome was positive (B563-565). The reward these nurses described I referred to as
completion brings reward .Fay explained the reason why she was asking the nurse in
Queensland, questions about the patient, was because ‘that’s what we’re here for’
(F:858). Although, at the end of the day, Fay felt she hadn’t done enough for the patient
(F:957). ‘I suppose I really don’t feel that sense of achievement ‘cos I never saw anything
through’ (F: 938-939). I interpreted this slightly differently as completion brings the
‘greatest’ reward; and what I mean is, achievement of patient outcomes was important to
the participants. However, Fay said she ‘felt good, ‘I felt really good that – you feel you
can achie[ve], you can provide something to the patient’ (F:960-961). The re-ocurrence
of ‘feeling good’ provides the means to celebrate nursing practice. The ‘good feeling’
described in the stories is a feeling of professional pride (Harvey & Tveit, 1994:53;
Brunner, 1998:5).
Being in control
This theme of being in control was uniquely evident in all of the stories. Each individual
participant brought unique personality traits to their situation, which affected their being
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in control. Naturally the context of the incident determined what degree of control the
participant assumed.
Di took control of the emergency situation, after being called upon to assist. The
impressive words that suggested Di was in control were ‘directing’, ‘instructed’,
‘organised’. She felt guilty after the event, having taken control of the situation from the
medical intern: ‘ …the nursing staff were the ones in control of the situation …’ (D:360-
361). Di did not hesitate in making the decision to take control, however. Being in
control also meant dealing with the situation as a whole, and in this sense Di prioritised
patient care, provided reassurance to family members, ensured ward activity and patient
care ran smoothly after the emergency, supported, educated and debriefed nursing staff.
Di reported the incident to her Clinical Nurse Consultant (CNC), in which she raised
issues of concern. Being in control meant managing the ward, often attending to several
tasks at once. By the end of the shift, Di was assured all nursing duties had been attended
to:
… once the patients had settled, visitors gone, things were under
control, drug rounds had been done and I knew everything was up to
date. Yeah at both ends… (D:313-315)
When Di was certain everything was under control, she discussed the emergency with the
enrolled nurse. Di ensured staff left work on time, which stands testament to her ability to
manage the ward, which was very much second nature for her. Di equated feeling
competent (under these circumstances), with ‘good nursing’. ‘I umm felt competent and I
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felt we’d done a good job’ (D:349). Being in control and being seen as a competent nurse
was important to Di, which is why she chose her particular story.
For Gina being in control meant having the authority to make decisions and taking
responsibility for organising whatever was necessary for her patient’s care. The ability to
work autonomously within the orthopaedic team left Gina feel valued and rewarded. Her
decision making ‘above what you’d be doing on the ward’ (G:589-590) and the higher
level of interaction with the medical team allowed Gina to feel in control. She stressed
this several times throughout our conversation, and I sensed it was very important to her.
Ellen took control of a situation she discovered when visiting the ward. On immediately
visualising the slipped traction, Ellen knew ‘ … something needed to be done about it
straight away’ (E:77). Indeed once the patient’s traction had been reapplied correctly,
control had effectively been restored. Ellen’s ability to control and organise the situation
contrasted markedly with the registered nurses inability to control the end of the ward to
which she was working that shift.
She wasn’t the most organised person…she hadn’t prioritised the
[patients’] needs in order of priority of need. (E: 182-184)
Ellen refers to the registered nurses lack of prioritisation and organisational skills, and
inability to control the situation, which implies these are characteristics Ellen would
expect of this nurse, and consider necessary in a senior nursing position.
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Ben, like Di, was called upon to take control of a situation because he was the most
senior orthopaedic nurse working that shift. Ben took control of the situation because
… no-one else had any idea about the sort of traction, especially
Thomas splints, no-one had even heard of Thomas splint let alone knew
how to put one on… (B:80-82)
Ben organised the traction equipment, and co-ordinated application of the splint and
traction. Concurrently Ben was expected to monitor the patient, supervise the other
registered nurse in accordance with and,
…abiding by the (the) guidelines of hospital policies and procedures
and all those other things, and by the Acts and all that sort of stuff…
(B:352-353)
He reviewed the ward situation from time to time as well. Ben also arranged the patient’s
transfer off the ward, to a ward where the patient could be more closely observed. Like
Di, being in control meant directing and managing the team under what would be
considered as extraordinary ward circumstances. Ben found humour assisted in this task,
and he thought afterwards they worked well as a team (B:564). Ben’s example of
managing a complex situation demonstrates the multi-dimensional aspects of being in
control.
Anne quietly and calmly assumed control. To Anne being in control meant being a co-
ordinator. By virtue of her position as Clinical Nurse Consultant, she already was in
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control of the ward. So this incident required Anne to maintain control. This was
achieved by leading by example:
… acting as a leader just directing and making sure that everything
was going smoothly; keeping everyone calm and relaxed. (A:253-254)
Anne monitored the patient, assisted the consultant, supervised the registered nurse,
ensured the procedure went smoothly, and afterwards ensured the documentation was in
order, that nursing staff were educationally prepared to care for this patient and there was
adequate staffing for the next twenty four hours or so. For Anne being in control required
little effort.
Carol was in charge of the ward and responsible for overall ward management when the
patient unexpectedly arrived on the ward. Carol took control of the admission because
she considered it to be the most natural thing to do. This type of admission tended to be ‘
… very complicated because the paper work doesn’t come up with the patient; because
they haven’t really been admitted … ’ (C:99-100) and because of the potential for this
sort of admission to re-occur. Carol dealt with the immediate matter of getting the patient
comfortable and medically assessed. Then she delegated the patient to a member of her
nursing staff. Once control had been resumed ‘ … once I got that under control, as much
control as you can … ’ (C:121-122), Carol followed the matter up further. Carol was
disappointed the admission ‘hadn’t run smoothly’ (C:526), therefore it was important to
her to do what she had to do, to ensure the ward did run smoothly and remain under
control. Furthermore, Carol believed control was related to advanced practice.
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I think it’s [advanced practice] is also about, ahh, being aware of how
an institution functions, how a hierarchy functions. The way things are
supposed to go correctly, and the channels to follow if they don’t
(C: 734-736)
This implies Carol believes organisational control, or managing control within an
organisation, is consistent with the role of advanced nurse practitioner.
Not only did Carol’s story highlight being in control of the ward situation, but also being
in control of herself. Carol mentioned her efforts to maintain her own composure; her
self-control related to her professionalism. I was impressed by Carol’s strong sense of
professional identity.
Fay also had responsibility for ward management. Fay was in control throughout the
twenty-four hours she was involved with this patient’s care. She attended to the different
aspects of managing the situation in a way similar to the other participants, by
prioritising, organising, liaising and initiating. However what impressed me most about
Fay’s being in control was in her giving control back to the patient. The patient wanted to
go outside the ward and have a cigarette. Fay explained to the patient the effect smoking
has on the body’s ability to heal, but she surmised,
… [smoking] seems to be like a crutch that they [patients] need it, so
they’ve got some control in their lives. I think he felt very out of
control. (F:547-548)
Fay’s actions were oriented toward the patient regaining control which was an extension
of her being in control. Sutton and Smith (1995a:144) suggest advanced practitioners
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adopt the role of patient advocate until the patient ‘is able to do this for themselves’. Fay
enabled the patient to achieve this.
Decision making
The ability to make decisions is related to being in control. I have attempted to describe
how each participant did this. Di made decisions in an emergency, which were second
nature. Gina makes decisions based on her assessment of the patient, such as a referral to
a cardiologist, and discharge planning needs. She says she has to make some very
responsible decisions when booking patients into the operating theatre. She makes
decisions above what an ordinary nurse on the ward would make. She enjoys the
responsibility making decisions brings. Ellen decides to turn the situation around in to a
learning opportunity for the nurse concerned. Ben has to make ‘a tricky decision’ to
clinically intervene or not. He struggles to make this decision to some extent, but does so.
He is then quite clear about what this decision will mean. Ben is certain of his decision to
transfer the patient from the ward. Anne makes decisions that are orderly and
unequivocal. She was certain that ‘I shouldn’t proceed with a procedure that I wasn’t
comfortable with’ (A:151-152). Carol was very clear about her priorities and following
the matter up: ‘It was something I would of made myself go and do because I felt strongly
about it and I like to follow my principles’ (C:497-499). These examples demonstrate that
decision making, is essential in being in control and managing complex situations.
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Anticipation
The theme of anticipation is related to being in control and maintaining control. Di
insists the medical intern secure intravenous access in the event of the patient having a
second cardio-pulmonary arrest. Gina anticipates her patient’s surgical operation may be
delayed, she therefore prepares the patient for this eventuality. It’s Gina’s job to predict
and plan for discharge. Gina anticipates this patient may take longer to recover from her
knee surgery. Ben anticipates his patient’s bone may pierce through the skin, so he
prepares the skin with an antiseptic lotion. Ellen anticipates problems, knowing that this
particular nurse is on duty. Anne looks ahead at the staffing arrangements because she
anticipates the need for senior staff having to look after this unusual method of treatment.
Carol anticipates this patient will need more space around his bed during his recovery,
she therefore places him in a bed by the window. She follows up the issue of
inappropriate ward admissions, to prevent it from happening again. Fay anticipates the
patient may arrive unannounced, so she notifies the casualty department and the other
orthopaedic wards. She anticipates the need for plastic surgeon’s intervention, so she
suggests they be involved in her patient’s care. The role of anticipation in the
participant’s nursing practice is best represented by Fay:
… you start thinking on your feet. You start thinking ahead of what
things can go wrong and then trying to fix them before they actually
occur, or intervening before they occur… (F:980-982)
Managing a complex situation was demonstrated by the participants in one way or
another by being in control, making decisions and anticipation of needs. Being in control
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is contextually driven and comprises several attributes. Each participant demonstrated
‘perception in skilled performance’ which Benner (1984:37) identified as evidence of
masterful performance. Benner (1984:109-10) identified seven domains of nursing
practice, amongst which was the ‘effective management of rapidly changing situations’
exemplified by an ability to quickly problem solve, intervene, seek assistance if required.
Benner suggests (1984:119) managing the situation which includes preventing crises as
well. The participants demonstrated an ability to do this, evidenced in the themes of being
in control, decision making and anticipation
Summary
This chapter has expanded upon the concepts that began to emerge from the participant’s
stories in chapter five and developed the following themes that describe advanced
orthopaedic nurse practice for the participants interviewed in this study. They are: having
knowledge, being in the role and outside the role, being an advocate and being in control.
These themes have been woven into a linguistic transformation that comprised the
phenomenological text.
Seven orthopaedic nurses described to me a situation in which they believed they
performed at an advanced level. Through thematic analysis of these seven descriptions,
concepts emerged which were developed into themes through a process of hermeneutic
interpretation. A constant movement between the parts (each participant’s story) and
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whole (the emerging themes) of the hermeneutic circle revealed a possible understanding
of what it means to be an advanced orthopaedic nurse practitioner.
Having knowledge emerged as a strong theme amongst the participants. Specific
orthopaedic knowledge underpinned the actions of these nurses but it wasn’t the only
form of knowledge highlighted. Knowledge was comprised of experience, education,
intuition, perceptions and impressions. Knowledge was developed through reflection and
operationalised through the use of prior examples in practice, or exemplars.
Being in the role and outside the role was exemplified by professionalism, a sense of
responsibility and obligation, and evidenced, as the participants described, by being an
initiator, co-ordinator, organiser, educator or leader. Role definition was sometimes
blurred and this led to conflict in some instances. Being outside the role, stretched the
boundaries of collegial and collaborative practice at times and was sometimes associated
with feelings of guilt, misgiving or inner conflict. Equally however being in the role and
outside the role engendered clarity, commitment and a strong sense of self.
Being an advocate held a strong presence in each description and was expressed in the
context of ‘my concern’. This abiding concern underpinned the nurses every action.
Feelings of reward for the participants originated in the achievement of patient outcomes.
A relationship between patient advocacy and a sense of completion emerged from the
descriptions, exemplified in ‘that’s what we’re here for’. Furthermore advocacy
manifested as staff advocacy too.
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The last theme identified was being in control or managing complex situations. Being in
control was related to individual participant characteristics as much as contextually
related. Being in control was viewed as a desirable ability to have in the context of
advanced practice. Making decisions and anticipation were related to the theme of being
in control and were clearly demonstrated by the participants in the management of their
sometimes, complex situations.
This chapter has explicated the themes that emerged from the descriptions of seven
orthopaedic nurses. To what extent these themes represent advanced practice this study
will now turn, as the meaning and understanding evolves.
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Chapter 7
Denouement
… it’s funny when you talk about it, some stuff you just do, you don’t
even think about it, it’s weird … (B: 454-455)
Introduction
This chapter will summarise my interpretation of advanced practice of the orthopaedic
nurse. This interpretation was made possible by analysing the personal experiences of
seven orthopaedic nurses. Their stories focussed on making visible an interpretation of
experience, as it is lived, in everyday orthopaedic nurse practice. My interpretation
therefore highlights the meaning and understanding of advanced orthopaedic nurse
practice. It is only one interpretation however. An enduring interpretation is made
possible through repeated readings of the phenomenological text. I therefore ‘hand over’
the prospect of future interpretations of my work to you, the reader.
It was important for me to engage orthopaedic nurses in this contemporary debate over
what constitutes advanced practice. This study has attempted to conceptualise advanced
practice through examination of the descriptions of seven advanced orthopaedic nurses.
This study attempted to understand not only the meaning but also the significance of
advanced orthopaedic nurse practice.
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Original Thoughts
This study has demonstrated the meaningful aspects of advanced orthopaedic nurse
practice. As the researcher, I recognised I was involved in the world of my participants
(Oiler, 82:179). I therefore revisited my taped self-interview of an incident I was
involved in as an advanced nurse. I listened again to my original thoughts and feelings on
advanced nursing, with a new perspective of the knowledge gained from this study. It
was heartening to discover that the findings of this study confirmed my initial thoughts
on advanced practice and those thoughts I had developed before commencing interpretive
analysis (fldnte:15). I found the impressive words and phrases from the participant’s
descriptions were revealed in my own interview. My experiences were the collective
experiences (van Manen, 1990:57). As part of ‘sharing the experience’ I found myself at
times ‘debriefing’ the incidents with the participants. This was performed willingly and
sensitively.
Perhaps I gravitated to my pre-understandings in the texts of the participants? I prefer to
believe my pre-understandings enriched the interpretation. Perhaps I could have added
more substance to this study, by directly observing advanced nurses in practice; time
prevented this. Providing clinical reasoning occurs in the context of ‘real practice’, as this
study has established, then the findings have relevance (Greenwood & King, 1995:908).
This study did not address the issue of orthopaedic nursing’s specialty status. It remains
an issue of significance to me however, and a commitment has been given to the South
Australian Orthopaedic Nurses (SAON) association to share the knowledge I have gained
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from this study and assist resolution of the perceived ‘crisis in confidence’ the specialty is
experiencing.
Significance and Implications for Practice
The seven nurses involved in this study described an incident in which they believed they
performed at an advanced level. Interestingly five of the seven nurses described what
would be considered as ‘extraordinary events’ in the otherwise ordinary activities of the
orthopaedic nurse. This is consistent with Benner’s (1984) notion that critical incident
analysis uncovers the knowledge embedded in practice. It is claimed knowledge is
operationalised in these ‘memorable or outstanding’ clinical events (Greenwood & King,
1995:908).
The participants attributed having knowledge as being an essential component to practice
at an advanced level. Certainly, each participant drew on specialist orthopaedic
knowledge, however a breadth of knowledge was evident in the stories. Having
knowledge comprised different types of knowledges, of which specialty nursing
knowledge was only one aspect, not necessarily considered integral to advanced practice
(Pearson, 1984:16). Retention and development of unique orthopaedic knowledge is
necessary to ensure the nursing specialty does not become ‘a dying art’. The pursuit of a
theoretical base for nursing has increasingly become evident within the literature, to
which this study will contribute in part by highlighting the need for further investigation
into the areas of specialist/expert/advanced nursing knowledge. When the concept of
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advanced nursing practice is clearer, and this can only be achieved through further
investigation, development of ‘advanced knowledge’ can be encouraged.
Commonalities and differences were exemplified in the theme being in the role and
outside the role. The participants expressed mixed emotions regarding being outside the
role. It appeared the more senior the advanced practitioners, the more comfortable they
felt being outside the role when compared to their inexperienced colleagues. It appears
advanced practice is a matter of perspective. However the ‘value’ of expert/advanced
nursing practice has not been adequately quantified in the extant literature (Borbasi,
1999:22 & 28).
This study suggested the role of the advanced practice nurse is many and varied. The
challenge to define advanced practice is complicated by the different interpretations of,
and contexts in which advanced practitioners are found. From the discussions
surrounding the nurse practitioner role for example, a renewed interest in delineating the
nursing role has emerged. It has been characterised as possessing an ‘intimacy, flexibility
and constancy’, which will continue to evolve in response to the increasing demands
placed upon it (Chiarella, 1998:31). The effort to define advanced practice must reflect
the uniqueness and diversity within modern nursing practice. The value in clarifying the
role of advanced practice should not be underestimated. It is necessary therefore, for the
nursing profession to recognise the resource or ‘wealth of knowledge’ that advanced
practitioners possess. Identification of the breadth of the advanced nursing role should be
promoted so that all health professionals can benefit. Furthermore the nursing profession
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must seriously consider how it prepares its expert nurses for advanced practice.
Mentoring and forums that discuss and validate feelings associated with being outside the
role should be encouraged
One role the participants of this study were unequivocal about, was that of being an
advocate. Patient advocacy in particular, maintained a powerful presence in each of the
descriptions. It was a strong, unifying theme throughout the narrative that explained the
motivations and actions of each participant, embodied in the phrase ‘that’s what I’m here
for’ (D:373 & F:858). Nurses take their patient advocacy role extremely seriously. The
advanced nurse considers patient advocacy as central to their practice. (Sutton & Smith,
1995a:144-5). Holistic thinking becomes the province of the expert/advanced nurse
(Jasper, 1994:772). A strong sense of self is often required to be an effective advocate:
The need for and the capacity to care have been described as universal
requirements reflecting an important aspect of our human nature,
affecting our perceptions of ourselves and our relations with others.
(Heidegger 1962 cited by Kitson, 1987:324)
It is important to celebrate the role of patient advocate that nurses enact. Through the
sharing of clinical exemplars, the uniqueness of our practice is realised (Harvey & Tveit,
1994:53). We must also recognise that sometimes the nurse advocate comes into conflict
in their role as an employee, sharing these experiences amongst nursing colleagues will
guide future practice.
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The ability to manage complex situations was demonstrated by the participants in each
description. Being in control, maintaining control, restoring control is expected from
advanced nurses, either of themselves or by their colleagues. It is about the smooth
resumption of a manageable situation. Making decisions and anticipation were activities
synonymous with being in control. The advanced nurse’s ability to do this is imperative.
How does the advanced nurse do this? It is not something easily taught. Encouraging
reflective practice however, and further research will clarify what is involved in
managing complex situations.
The meaning of advanced practice for the expert orthopaedic nurse is, I suspect, not
unlike the practice of any other advanced practice nurse. Whilst orthopaedic nurses
possess unique knowledge, the focus and the characteristics of the nursing role is
universal. The participant’s described ‘extraordinary’ orthopaedic experiences, yet
managed these situations in an ‘ordinary’ and advanced way. The development of generic
competency standards of advanced practice, both in Australia and in the United
Kingdom, supports the notion that commonality in performance exists amongst advanced
practitioners. Furthermore, a continuum of expert to advanced practice exists (much like
Benner’s (1984) novice to expert sequential acquisition of skills). The participants in this
study demonstrated a breadth of advanced nursing performance. Some were expert, that
is their knowledge gained from experience, meant that they cared for their patient in an
expert way. Their advanced practice was in a state of emergence however. The subtle
transition to advanced practice occurs in the context of the patient – nurse relationship.
There is a qualitative difference in how the advanced nurse practitioner thinks, sees and
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experiences nursing practice (Sutton & Smith 1995b:1040). This was evident in the
comprehensive descriptions of nursing practice from Anne, Carol and Fay. Their
perspective effortlessly conveyed a knowledge of the fullest extent of a situation. If the
nursing profession is serious about advanced nurse practice, then the onus is on it to
develop and prepare advanced nurse practitioners. This must be done in an orderly and
coordinated way, so as to avoid any further confusion. I believe the application of generic
competency standards for the advanced nurse will assist in this transition. My desire is to
see the acceptance of generic competency standards for the advanced nurse, into the
practice of orthopaedic nurse practitioners.
Sutton and Smith (1995a:145) suggest advanced nursing practice is the essence of
nursing. But what benefit is this claim to ordinary nurses? The claim that ‘all
practitioners have value in the delivery of health service’ must not be lost in this debate
on advanced practice (Humphries, 1998:13). Benner (1984:35) believed the study of
proficient and expert performance developed knowledge that would form the basis of
excellence in nursing practice. This notion can be extended to expert and advanced
practice. An understanding of advanced nursing practice contextualises remaining
nursing practice. Similarly an understanding of advanced nursing practice contextualises
orthopaedic nursing practice, that is provides a measuring stick if you like. In this way
this study has attempted to make a difference to all nurses. The extent to which the
patient benefits from advanced nursing practice, is an area worthy of further
investigation.
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Potential Ramifications
The nature and scope of advanced practice has yet to be agreed on in any definitive sense
(Clinton et al, 1999:18). Genuine progress appears to have been taken in reaching this
objective. How a nurse achieves advanced status is not known. Revealing the subtleties
of advanced practice will provide meaning and understanding of this complex concept.
This study has attempted to reveal the meaning of advanced orthopaedic nurse practice
by:
…presenting a description which is in some ways clearer and more
open to understanding than the individuals would have been able to
provide unassisted. (Ashworth, 1997:221)
In this way a contribution toward a general understanding of advanced practice was
generated.
As the debate on advanced practice continues, future possibilities will evolve. Benner
(1984) claimed ‘… there is a wealth of untapped knowledge embedded in the know-how
practice of expert nurse clinicians …’. A promising future awaits, as the wealth of
knowledge in nursing practice is revealed. However, nurses must apply an hermeneutical
approach to their nursing practice; that is, taking new knowledge gained from experience
and practice, and reapplying it back into practice (Reed 1998:79 cites Peplau). Nurse
practitioner trials are under way in which nurses will be suturing wounds and treating
uncomplicated fractures (Serghis, 1998:7). The outcome of these trials heralds exciting
possibilities in the context of advanced orthopaedic nurse practice.
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Future research efforts need to focus on further clarification of the concept of advanced
practice and evaluating the impact advanced nursing practice has on patient care and the
achievement of patient outcomes.
Evaluation of the Research Process
In order to determine whether this interpretation is sound, I have chosen to apply the
following evaluation ‘methodological principles’ suggested by Maddison (1990:29-30).
Interpretive agreement is not necessary, but the process of reaching interpretive
agreement is; that a ‘dialogue of understanding’ should emanate from this work
(Geanellos, 1998:158-9).
Coherence
The details and parts of the interpretation should be coherent and in harmony with the
whole picture depicted in the texts.
Throughout the interpretive process a movement back to the whole story of the
participants took place. Emerging concepts were referenced from the original
participant’s description and coded accordingly.
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Comprehensiveness
The interpretation should relate to the total picture depicted in the texts.
An extension of the above principle, emerging themes were exemplified by reference to
‘patterns of meaning’ or examples from within the participant’s description.
Penetration
The degree to which the interpretation achieves what the researcher set out to do.
This study set out to discover the meaning of advanced practice for the expert
orthopaedic nurse practitioner. The thoughts, feelings and perceptions of the seven
expert/advanced, orthopaedic nurse practitioners were presented in chapters five and six.
These feelings were transformed into the interpretation of this study.
Thoroughness
The interpretation attempts to answer the questions it poses to the text and those posed by
the text.
An ongoing dialogue with the text provided an entrée into the questions raised by the
text; and questions asked of the text. The interpretation gleaned from this process, was
presented in chapter six.
126
Appropriateness
The interpretation should deal with those questions raised by the text itself.
Chapter six comprises the interpretation, which contained the answer to the questions
posed by the text.
Contextuality
The interpretation is in keeping with the historical and contextual nature of the text.
Chapter four explains the participant’s background. Chapter five summarises the
participant’s stories and thereby describes the individual nurse’s own context within their
description. Paradigm cases were further contextualised by reference to literature-in-the-
field. There is a phenomenological tradition associated with this study’s research topic,
therefore use of this particular methodology adds to the historical context of the research.
Agreement
The interpretation should agree with what the text is saying and not manipulate the
meaning of the texts.
From the outset I was sensitive to the need for a ‘pure’ interpretation. I conducted a self-
interview, the purpose of which was to identify with the participants in terms of
replicating interview conditions, and to declare my pre-understandings towards the
phenomenon. However my original understanding of the phenomenon was transformed
127
by the process of this study. By accurately referenced excerpts from the participant’s
narratives in support of concepts and themes, agreement has been possible.
Suggestiveness
The degree to which the interpretation stimulates further research.
In the absence of orthopaedic nursing literature-in-the-field, this study raises questions
about the relationship between orthopaedic nursing practice and advanced practice.
Potential
The degree to which the interpretation can be extended in the future.
The question remains as to whether advanced practice makes a difference to the
orthopaedic patient, and further does advanced practice make a difference to the
experience of the patient and health outcomes generally.
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A Final Comment
This study has attempted to reveal the meaning of advanced practice in the context of
orthopaedic nursing practice. This study provides one perspective. If you have reacted,
agreed, disagreed, or identified with the experiences of this study, then I am satisfied the
study has accomplished what it set out to do. van Manen (1990:27) refers to the
‘phenomenological nod’; if this describes your reaction, then the study has value as a
‘good’ phenomenological description.
My experience of this study as an orthopaedic nurse, has transformed my understanding
of advanced practice, and will inform my future nursing practice. I should like to revisit
the opening quote of this chapter ‘… it’s funny when you talk about it, some stuff you just
do, you don’t even think about it, it’s weird …’ (B:454-455). Ben’s words are a validation
of the ‘… multiple interpretive layers of this research process and practice …’ (Koch,
1996:182); they carry such resonance that confirms this is not an end; there will always
be another possibility.
129
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Appendix 1
Information Sheet to Participants
Dear
Thank you for considering to take part in my research proposal titled "Advanced Practice
and the Orthopaedic Nurse: An Interpretive Study". I am a Registered Nurse working on
an orthopaedic ward at the RAH. I am currently undertaking a Masters of Nursing
Science. The award requires me to undertake some form of research. I am interested in
describing advanced practice of the expert orthopaedic nurse. It is hoped the information
gained from the study will contribute to the debate on advanced practice. To date
orthopaedic nurse involvement has been minimal, therefore this study aims to engage
orthopaedic nurses in the debate and in so doing put an "orthopaedic" perspective on
advanced practice.
I envisage your commitment will be as follows:
Up to one (1) hour of your personal time is required to conduct the taped interview,
which forms the body of the research. Then a shorter session in which I would like to
verify my interpretation of the initial interview with you. Finally a feedback session in
which I would like to advise you of the results of the study. This may be conducted in
writing if you prefer.
Please be reminded inclusion is entirely voluntary on your part. You may withdraw from
the study at any time. Privacy, confidentialty and anonymity is guaranteed.
Should you wish to discuss this proposal please don't hesitate to contact me on 8379
3413. You may also contact the Chairman, Research Ethics Committee on 8222 4139 if
you wish to further discuss aspects of the study. If you are still interested in taking part
please complete the attached consent form and return in the envelope provided. I shall
contact you shortly to arrange an interview time.
Thanking you in anticipation.
Yours sincerely
Anita Taylor
136
Appendix 2
Consent Form
Project Title: "Advanced Practice and the Orthopaedic Nurse: An Interpretive Study"
Researcher: Anita Taylor
This is to certify that I
_____________________________________________________________________
(print name)
agree to participate as a volunteer in the above named project. I give permission to be
interviewed and for those interviews to be tape recorded.
The nature and purpose of the research project has been explained to me by the
researcher. I have been given the opportunity to ask whatever questions I desire, and all
such questions have been answered to my satisfaction.
I understand that, while information gained during the study may be published, I will not
be identified nor any other persons or institution; and such information shall remain
confidential.
I understand that I can withdraw from the study at any stage or refuse to answer any
question of my choosing, without penalty.
_____________________ _____________________ __________________
participant researcher date
